Domestic Violence Screening/Documentation Form

Domestic Violence Screening/Documentation Form
Family Violence Prevention Fund and Educational Programs Associates‚ Inc. 1996
غربالگری خشونت خانگی
DOMESTIC VIOLENCE SCREENING/DOCUMENTATION FORM FEMALE
ASSESS PATIENT SAFETY
Is abuser here now?  YES‚ NO
Is patient afraid of their partner?  YES‚ NO
Is patient afraid to go home?  YES‚ NO
Has physical violence increased in severity? YES NO
Has partner physically abused children?  YES‚ NO
Threats of homicide?  YES‚ NO
By whom: ______________________
Threats of suicide?  YES‚ NO
By whom: _____________________
Is there a gun in the home?  YES‚ NO
Alcohol or substance abuse?  YES‚ NO
Was safety plan discussed?  YES‚ NO
INTERVENTION
Were safety planning options discussed? YES‚ NO
ABUSE ASSESSMENT
Has your partner ever put his/her hands on you in ways that you didn’t want (push‚ pinch‚ restrain‚ wrestle when you didn’t want to‚ etc.)?
 Who?
Has anyone ever forced you to do anything sexually you did not want to do?
Who? Have you been forced into unwanted sexual activities in the last 72 hours?
Are you afraid of anyone?
Who?
Does anyone criticize you‚ make you feel bad about yourself‚ or try to control you?
Who?
REFERRALS
Hotline number given …
Legal referral made …
Shelter number given …
In house referral made …
Describe: ___________________
Other referral made …
Describe: ___________________
REPORTING
Law enforcement report made …
Child Protective Services report made …
Adult Protective Services report made …
PHOTOGRAPHS
Consent to be photographed? YES‚ NO
Photographs taken? YES‚ NO
Attach photographs and consent form
DOMESTIC VIOLENCE SCREENING/DOCUMENTATION FORM MALE
ABUSE ASSESSMENT
Has your partner ever put his/her hands on you in ways that you didn’t want? (push‚ pinch‚ restrain‚ wrestle when you didn’t want to‚ etc.)
Who?
Have you ever been forced into unwanted sexual activities?
Who?
Are you afraid of anyone?
Who?
Does anyone criticize you‚ make you feel bad about yourself‚ or try to control you?
Who?
REFERRALS
Hotline number given
Legal referral made
Shelter number given
In-house referral made
Describe: ________________________________
Other referral made
Describe: ________________________________
REPORTING
Law enforcement report made
Child Protective Services report made
Adult Protective Services report made
PHOTOGRAPHS
Yes No Consent to be photographed?
Yes No Photographs taken?
Attach photographs and consent form
ASSESS PATIENT SAFETY
Yes No Is abuser here now?
Yes No Is patient afraid of their partner?
Yes No Is patient afraid to go home?
Yes No Has physical violence increased in severity?
Yes No Has partner physically abused children?
Yes No Have children witnessed violence in the home?
Yes No Threats of homicide?
By whom: ____________________________________
Yes No Threats of suicide?
By whom: _____________________________________
Yes No Is there a gun in the home?
 Yes No Alcohol or substance?
INTERVENTION
 Yes No Were safety planning options discussed?
شرح سایت روان سنجی: فرمی است که مددکار حرفه ای خانگی به ارزیابی خشونت جسمی، ایمنی بیمار، وجود اسلحه و سوء مصرف مواد مخدر پرداخته و گزینه های گزارش و ارجاع دارد.
چگونگی دستیابی
منبع و ماخذ
Family Violence Prevention Fund (1996). Health alert: Strengthening the health care system’s response to domestic violence. San Francisco‚ CA: Author.
Cassidy K (1999). How to assess and intervene in domestic violence situations. Home Healthcare Nurse‚ 17‚ 664-72.
Family Violence Prevention Fund (2002). National consensus guidelines on identifying and responding to domestic violence victimization in health care settings. San Francisco‚ CA: Author.
   
خرداد 1396
اسفند 1395
آبان 1395
فروردین 1394
خرداد 1393
فروردین 1393
اسفند 1392
بهمن 1392
دی 1390
آذر 1390
تیر 1390
خرداد 1390
اردیبهشت 1390
بهمن 1389
دی 1389
اردیبهشت 1389
دی 1388
آبان 1388
شهریور 1388
مرداد 1388
تیر 1388
خرداد 1388
   

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