Optional Health Assessment Modules Form Page 20
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27OPTIONAL MODULE 10:
UR Number:
FAMILY VIOLENCE
Surname:
Given name:
(DHS Identifying Family Violence
Date of birth:
Recording Template)
(Please fill in if no label available)
PURPOSE OF MODULE
INSTRUCTIONS
To record experiences of family violence.
1. Assess whether any possible indicators of family violence have been mentioned (a list of
indicators is included in clinician guide).
WHO CAN ADMINISTER THIS MODULE?
2. Ask suggested prompting question/s if appropriate (see list in clinician guide).
This module should only be completed by clinicians
3. Fill out recording template and refer to a family violence worker or service as appropriate. If
who have been trained or feel confident in
trained in family violence assessment, consider completing the preliminary assessment found
here:
identifying and recording family violence.
VICTIM
Family name
First name
Second name
Other names/aliases
Preferred name/s
Current address
Postcode
Phone numbers:
Home
Work
Mobile
Preferred phone number
Can you leave a message?
No
Yes
Date of birth
/
/
Age
Gender identity
Country of birth
Language/dialect(s) Spoken at home
Interpreter required
No
Yes (specify language /dialect)
Aboriginal and/or Torres Strait Islander
Aboriginal
T.S.I.
Both
Neither
Unknown
Disability
No
Yes (specify nature of disability)
Relationship to perpetrator
Wife
Defacto wife
Former wife (including defacto)
Husband
Defacto husband
Partner
Former husband (including defacto)
Girlfriend
Former girlfriend
Carer
Boyfriend
Son
Daughter
Brother
Sister
Former boyfriend
Father
Mother
Other (please specify)
Does the perpetrator live in your household?
No
Yes
Are there any children living in your household?
No
Yes (please specify)
Emergency contact
Name
Phone number
Income source
Visa category
Carer
No
Yes (please specify)
Any additional needs (e.g. communication aid, medication,
No
Yes (please specify)
personal care attendants, special dietary requirements?)
FOR STAFF ONLY
Clinician name:
Position:
Signature:
Date:
19
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