Risk Factor Coding Form

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


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