Family Violence Intervention Program Survey

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* 2. Contact information

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

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* 3. Date

Date

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* 4. Who Referred You

DSS

Court

Self

Other (please specify)

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* 5. Was there a police report

Yes

Other (please specify)

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* 6. What is your age?

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* 7. Race/Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Another race

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* 8. Gender

Female

Male

Non-binary

Prefer not to say

Other (please specify)

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* 9. Sexual Orientation

Heterosexual

Gay

Bisexual

Lesbian

Asexual

pansexual

Prefer not to identify

Other (please specify)

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* 10. Are you currently employed?

Full-time

Part-time

Unemployed

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* 11. Are you Disabled?

Yes

Other (please specify)

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* 12. Are you a Student?*

Yes

Other (please specify)

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* 13. Family Size

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* 14. How many Minor Children live in the house hold

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* 15. What is your current monthly income?

<$1,000

$1,000-$1,999

$2,000-$2,999

$3,000-$4,000

>$4,000

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* 16. Household Income

Under $15,000

Between $15,000 and $29,999

Between $30,000 and $49,999

Between $50,000 and $74,999

Between $75,000 and $99,999

Between $100,000 and $150,000

Over $150,000

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* 17. History

Child Abuse (Physical)

Child Abuse (Sexual)

Child Abuse (Incest)

Child Pornography

Child Domestic Violence Witness

Kidnapping (non-custodial)

Kidnapping (custodial)

Teen Dating Victimization

Domestic Violence

Protective Order

Elder Abuse

Stalking/harassment

DUI/DWI Crashes

Other Vehicular ( e.g. hit and run)

Terrorism (domestic/international)

Other Victim of Crime

Emergency Medical Services

Law Enforcement Intervention

Open/Past Mental Health History

Open/Past Dept. of Juvenile Justice

Open/Current Criminal History

Arson

Adult Sexual Assault

Adult Physical Assault

Robbery/Burglary

Bullying

Hate Crime

Human Trafficking: Labor

Identity theft/financial crime

Alcohol Abuse

Drug Abuse

Survivor of Homicide Victim

None of the above

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* 18. Special Classification of Individuals
Please select all that apply

Deaf/hard of hearing

Homeless

Immigrants/refugees/asylum seekers

Limited English proficiency

Disabled: physical/mental/intellectual

Veterans

None of the above

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* 19. Do you have a high school diploma or GED?

If you do not have a high school diploma or GED, we can assist you! Ask your counselor about the Financial Freedom program.

Yes

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* 20. In the last year, has your intimate partner done any of the following:

	Daily	Weekly	Monthly	Once	Never	Other
Yelled at you	Yelled at you Daily	Yelled at you Weekly	Yelled at you Monthly	Yelled at you Once	Yelled at you Never	Yelled at you Other
If other, please specify:
Threatened to hit you	Threatened to hit you Daily	Threatened to hit you Weekly	Threatened to hit you Monthly	Threatened to hit you Once	Threatened to hit you Never	Threatened to hit you Other
If other, please specify:
Threatened to kill you	Threatened to kill you Daily	Threatened to kill you Weekly	Threatened to kill you Monthly	Threatened to kill you Once	Threatened to kill you Never	Threatened to kill you Other
If other, please specify:
Threatened to hurt the children	Threatened to hurt the children Daily	Threatened to hurt the children Weekly	Threatened to hurt the children Monthly	Threatened to hurt the children Once	Threatened to hurt the children Never	Threatened to hurt the children Other
If other, please specify:
Grabbed or pushed you	Grabbed or pushed you Daily	Grabbed or pushed you Weekly	Grabbed or pushed you Monthly	Grabbed or pushed you Once	Grabbed or pushed you Never	Grabbed or pushed you Other
If other, please specify:
Hit or slapped you	Hit or slapped you Daily	Hit or slapped you Weekly	Hit or slapped you Monthly	Hit or slapped you Once	Hit or slapped you Never	Hit or slapped you Other
If other, please specify:

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* 21. What did you do when these things happened to you? (Select all that apply)

Nothing

Left the house or place where the incident occurred by myself

Left the house or place where the incident occurred with my children

Yelled back

Grabbed or pushed back

Hit or slapped back

Other (please specify)

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* 22. List as many of the early warning signs of violent behavior as you can think of:

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* 23. Do you know what a safety plan is?

Yes

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* 24. Do you have a personal safety plan?

Yes

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* 25. Select the three (3) MOST IMPORTANT things you hope to accomplish through your participation in group:

Feel safe

Feel happier

Improve my sense of self worth

Get my children back

Provide a better life for myself

Learn why abusers do what they do

I'm not sure

Other (please specify)

Family Violence Intervention Program

Pre-Group Survey

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* 1. Name

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* 2. Contact information

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* 3. Date

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* 4. Who Referred You

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* 5. Was there a police report

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* 6. What is your age?

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* 7. Race/Ethnicity

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* 8. Gender

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* 9. Sexual Orientation

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* 10. Are you currently employed?

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* 11. Are you Disabled?

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* 12. Are you a Student?*

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* 13. Family Size

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* 14. How many Minor Children live in the house hold

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* 15. What is your current monthly income?

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* 16. Household Income

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* 17. History

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* 18. Special Classification of IndividualsPlease select all that apply

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* 19. Do you have a high school diploma or GED?If you do not have a high school diploma or GED, we can assist you! Ask your counselor about the Financial Freedom program.

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* 20. In the last year, has your intimate partner done any of the following:

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* 21. What did you do when these things happened to you? (Select all that apply)

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* 22. List as many of the early warning signs of violent behavior as you can think of:

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* 23. Do you know what a safety plan is?

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* 24. Do you have a personal safety plan?

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* 25. Select the three (3) MOST IMPORTANT things you hope to accomplish through your participation in group:

* 18. Special Classification of Individuals
Please select all that apply

* 19. Do you have a high school diploma or GED?

If you do not have a high school diploma or GED, we can assist you! Ask your counselor about the Financial Freedom program.