Domestic Violence Survey Form Template
Understand and address domestic violence effectively
If you're looking to identify and address the serious issue of domestic violence, this template is tailored for you. It helps schools and organizations assess whether students or their families are experiencing domestic abuse, enabling timely intervention and support. You can easily gather crucial insights, ensure anonymity for respondents, and comply with privacy standards while fostering a safer environment. With accessible, WCAG-aligned labels, this form is user-friendly for all individuals. Start using this live template to make a difference today.
When to use this form
Use this confidential form to screen for safety, document experiences, and guide next steps. It fits intake at shelters, clinics, campus services, and community programs, or as an anonymous pulse check. Schools can pair it with the Teen stress survey form to understand student well-being and risk. If concerns affect a student plan, counselors can align follow-up with the Teacher input for IEP form. You can also adapt questions for remote or hybrid settings, as shown in the Learning modality survey form, to reach people who cannot speak freely at home. Results help you triage urgent cases, connect people to shelter or legal help, and track outcomes.
Must Ask Domestic Violence Survey Questions
- In the past 12 months, have you felt afraid of a partner or family member?
A clear timeframe improves recall and helps you gauge current risk. It guides triage so you can prioritize immediate safety planning when needed.
- What types of harm or control have you experienced (physical, sexual, emotional, digital, financial)?
Behavior categories help respondents name experiences without writing long narratives and reduce underreporting. They also map to tailored referrals and outreach, including remote contexts informed by the Learning modality survey form.
- Are children or other dependents involved or affected?
This reveals added risk and support needs, including custody, school safety, and caregiving. It informs coordinated services and any required reporting policies.
- What support do you want today (safety plan, shelter referral, legal information, medical care, counseling)?
Centering requested help increases trust and follow-through. It also lets staff route cases to the right resources without delay.
- Is it safe to contact you, and what is the best way and time to reach you?
Safe communication prevents accidental harm and protects privacy. Collecting preferred channels and timing improves engagement and respects boundaries.
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