Risk Factor Coding Form
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| Client Name: |
| Staff Name: |
| Date: |
| Risk Factor |
Code (A, P, Unk) |
| 1. History of violence outside of the family by perpetrator |
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| 2. History of domestic violence |
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| 3. Prior threats to kill victim |
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| 4. Prior threats with a weapon |
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| 5. Prior assault with a weapon |
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| 6. Prior threats to commit suicide by perpetrator |
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| 7. Prior suicide attempts by perpetrator* (if check #6 and/or #7 only count as one factor) |
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| 8. Prior attempts to isolate the victim |
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| 9. Controlled most or all of victim’s daily activities |
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| 10. Prior hostage-taking and/or forcible confinement |
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| 11. Prior forced sexual acts and/or assaults during sex |
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| 12. Child custody or access disputes |
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| 13. Prior destruction or deprivation of victim’s property |
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| 14. Prior violence against family pets |
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| 15. Prior assault on victim while pregnant |
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| 16. Choked/Strangled victim in the past |
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| 17. Perpetrator was abused and/or witnessed domestic violence as a child |
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| 18. Escalation of violence |
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| 19. Obsessive behaviour displayed by perpetrator |
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| 20. Perpetrator unemployed |
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| 21. Victim and perpetrator living common-law |
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| 22. Presence of stepchildren in the home |
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| 23. Extreme minimization and/or denial of spousal assault history |
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| 24. Actual or pending separation |
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| 25. Excessive alcohol and/or drug use by perpetrator |
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| 26. Depression “ in the opinion of family/friend/acquaintance “ perpetrator |
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| 27. Depression “ professionally diagnosed “ perpetrator (If check #26 and/or #27 only count as one factor) |
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| 28. Other mental health or psychiatric problems “ perpetrator |
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| 29. Access to or possession of any firearms |
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| 30. New partner in victim’s life |
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| 31. Failure to comply with authority “ perpetrator |
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| 32. Perpetrator exposed to/witnessed suicidal behaviour in family of origin |
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| 33. After risk assessment, perpetrator had access to victim |
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| 34. Youth of couple |
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| 35. Sexual jealousy “ perpetrator |
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| 36. Misogynistic attitudes “ perpetrator |
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| 37. Age disparity of couple |
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| 38. Victim’s intuitive sense of fear of perpetrator |
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| 39. Perpetrator threatened and/or harmed children |
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| Other factors that increased risk in this case? Specify:
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