Family and Domestic Violence Risk Assessment Tool

Service providers that have a role in responding to family and domestic violence are required to conduct a risk
assessment considering the adult victim’s assessment of the risk, evidenced based key risk factors and the service
provider’s professional judgement1.

1 Summary

Victim details Perpetrator details

Name: Click here to enter text. Name: Click here to enter text.

Date of birth: Click here to enter text. Date of birth: Click here to enter text.

Phone number: Click here to enter text. Phone number: Click here to enter text.

Address: Click here to enter text. Address: Click here to enter text.

Emergency contact: Click here to enter text.

Nature of relationship between victim / perpetrator: Click here to enter text.

Name(s) and date(s) of birth of children: Click here to enter text.

Completed by:

Name: Click here to enter text. Date completed: Click here to enter a date.

Agency: Click here to enter text. Phone: Click here to enter text.

Initial assessment

Level of FDV risk At HIGH RISK of serious harm At RISK of harm

Levels of risk are defined in Section 5 Assessment / Analysis.

Critical or imminent safety concerns

1
This risk assessment tool is based on comprehensive research including multiple examinations of the predictive accuracy of risk
factors, victim perception and professional judgement in assessing risk of repeat assault or potential lethality in family and
domestic violence cases (Campbell 2003; 2004; 2005). See Fact sheet 5 Key risk factors for further information and references.

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Please list any immediate concerns

Click here to enter text.

2 Risk factor identification

Violence toward victim/s
Source of information if not
Risk factor Yes No Unknown
adult victim (e.g. Police)

Was a weapon used by the perpetrator in most recent event* ☐ ☐ ☐ Click here to enter text.

Is the violence becoming worse or more frequent* ☐ ☐ ☐ Click here to enter text.

Has the perpetrator ever physically harmed or threatened to harm Click here to enter text.
☐ ☐ ☐
adult victim*

Has the perpetrator ever raped or sexually assaulted adult victim* ☐ ☐ ☐ Click here to enter text.

Has the perpetrator ever choked, strangled or suffocated the adult Click here to enter text.
☐ ☐ ☐
victim or attempted to do so*

Has the perpetrator ever tried or threatened to kill the adult victim* ☐ ☐ ☐ Click here to enter text.

Is the perpetrator stalking the adult victim (could include harassing Click here to enter text.
☐ ☐ ☐
and/or monitoring the adult victim using others and/or technology)*

Is the perpetrator jealous and/or controlling toward the adult victim* ☐ ☐ ☐ Click here to enter text.

Has there been a recent separation or planned separation in the Click here to enter text.
☐ ☐ ☐
near future*

Has the perpetrator ever harmed or threatened to harm or kill Click here to enter text.
☐ ☐ ☐
children*

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Has the perpetrator ever harmed or threatened to harm or kill pets Click here to enter text.
☐ ☐ ☐
or other animals*

Has the perpetrator ever harmed or threatened to harm or kill other Click here to enter text.
☐ ☐ ☐
family members

Has the perpetrator isolated the adult victim from family, friends Click here to enter text.
☐ ☐ ☐
and/or other social supports

Has the perpetrator restricted the adult victim’s access to money ☐ ☐ ☐ Click here to enter text.

Perpetrator
Source of information if not
Risk factor Yes No Unknown
adult victim (e.g. Police)

Does the perpetrator have access to firearms or prohibited Click here to enter text.
☐ ☐ ☐
weapons*

Has the perpetrator ever threatened or attempted suicide* ☐ ☐ ☐ Click here to enter text.

Does the perpetrator misuse/abuse drugs and/or alcohol* ☐ ☐ ☐ Click here to enter text.

Has the perpetrator ever experienced mental ill health# ☐ ☐ ☐ Click here to enter text.

Is the perpetrator unemployed ☐ ☐ ☐ Click here to enter text.

Is the perpetrator experiencing financial difficulties ☐ ☐ ☐ Click here to enter text.

Has the perpetrator breached any court orders (i.e. bail, violence Click here to enter text.
☐ ☐ ☐
restraining order and/or police order conditions)

Is the perpetrator currently on bail or parole in relation to violent Click here to enter text.
☐ ☐ ☐
offences

Has the perpetrator served a time of imprisonment or been Click here to enter text.
☐ ☐ ☐
released recently from custody in relation to violent offences

Does the perpetrator have a history of violent behaviour (not family Click here to enter text.
☐ ☐ ☐
violence)

Does the perpetrator’s family pose a risk to the adult victim ☐ ☐ ☐ Click here to enter text.
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 Children
Source of information if not adult
Risk factor Yes No Unknown
victim (e.g. Police)

Is the adult victim pregnant or is there a new birth* ☐ ☐ ☐ Click here to enter text.

Has the child ever been in the adult victim’s arms when Click here to enter text.
☐ ☐ ☐
she/he has been attacked*

Has the child ever tried to intervene in the violence ☐ ☐ ☐ Click here to enter text.

Are there child contact or residency issues and/or are Click here to enter text.
☐ ☐ ☐
there current Family Court proceedings

Are there children from a previous relationship present in Click here to enter text.
☐ ☐ ☐
the household

# The presence of mental ill health must be carefully considered in relation to the co-occurrence of other risk factors.
* These risk factors indicate an increased likelihood of a victim being killed.

3 Adult victim’s assessment of the risk

How fearful is the adult victim of the

perpetrator Not afraid Afraid Terrified Unable to answer

Click here to enter text.

What concerns did the adult victim

express?

Click here to enter text.

What did the adult victim think the

perpetrator might do and to whom?

Click here to enter text.

Other important comments

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4 Professional judgement

Click here to enter text.

Are you aware of any other additional
factors, circumstances or details which
make you believe there is risk or high risk
to the safety of the adult victim, children
and/or others?

Issues to consider may include: the adult Click here to enter text.
victim’s situation in relation to disability,
substance misuse, mental health issues,
cultural/ language barriers; whether they
are willing to engage with a support
service; whether the perpetrator’s
occupation or interests has given them
unique access to weapons etc.

Click here to enter text.

Do you believe any children in the

household are at risk of harm?

5 Assessment/Analysis

Level of Select appropriate level of risk based on professional judgement, evidenced base risk factors and the
victim's own perception of their level of risk where available.
FDV risk
At HIGH RISK of serious harm At RISK of harm

At high risk of serious harm means there is evidence of a At risk of harm means there is evidence
serious risk to the adult victim and children’s safety and of a risk to the adult victim and
wellbeing and urgent action is necessary to prevent or children’s safety and wellbeing.
lessen the risk.
A victim is identified as at risk of harm
A victim is identified as at high risk of serious harm if: if:
 a number of factors with an (*) are checked 'yes' on the risk  one or more risk factors are checked
assessment tool; 'yes' on the risk assessment tool;
 there is a history of physical violence by the perpetrator toward  there is a history of violence by the
the adult and child victims (if there are children); and/or perpetrator toward the adult and child
 in your professional judgement, combined with evidence based victims, and/or
risk factors, the adult and child victims (if there are children)  the violence is escalating.
are likely to be in grave danger if immediate action is not taken.

6 Responding to the level of risk

Next steps Details of action

Immediate safety addressed Click here to enter text.

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 Safety plans developed Click here to enter text.

Agency collaboration & information sharing Click here to enter text.

Warm referrals made for: Click here to enter text.

Adult victim

Children

Perpetrator

Multi-agency meeting convened Click here to enter text.

Police contacted Click here to enter text.

VRO application Click here to enter text.

Child protection notified Click here to enter text.

Other Click here to enter text.

Are these next steps working toward making it safer for the adult and child/ren victims?

Are these next steps holding the perpetrator accountable for their violence?

NB: The above is a non-exhaustive list of actions to be taken. Every case is unique and appropriate actions
will be dependent on the outcome of the family and domestic violence risk assessment.