Domestic Violence Screening Form Under the Family Violence Option (text version)
Completing this form is voluntary: You do not have to fill out this form to receive public assistance. It will not impact your eligibility for assistance1, the amount of assistance you receive or the length of time it takes to process your application.
If you are a victim of domestic violence and you think that meeting certain program requirement(s) will put you or your children at risk or make it harder for you to escape an abusive situation, you may ask for a temporary delay (waiver) of that requirement by filling out this form and meeting with a Domestic Violence Liaison (DVL). You may decide not to fill out this form right now but you are free to do so at any time. You may ask to see the DVL at any time.
Anything you disclose to the DVL, including your relationship with the person
who has abused you, will be kept confidential, with the exception of child
abuse and neglect.
You may complete this form and request to see a DVL regardless of your gender, sexual orientation or marital status. You do not have to have children or have left the abusive situation to meet with the DVL. You are not required to provide any information or details about the abusive situation to any worker before you are referred to the DVL.
Are you in danger of a family member, your partner or ex partner doing any of the following:
- Hitting, slapping, kicking, choking or in any way hurting you physically?
- Isolating you; making you feel like a prisoner, controlling what you can do?
- Threatening to harm you, your children, or someone close to you?
- Stalking you, following you or checking up on you?
- Shaming or belittling you, constantly putting you down and telling you that you are worthless?
- Forcing you to have sex when you don’t want to or into sexual acts that you do not want to participate in?
- Making you feel afraid?
- Yes: I would like to meet with a DVL to discuss my situation.
- Yes: But I do not want to meet with a DVL at this time.
- No: None of the situations described above apply to me or I do not wish to answer these questions at this time.
In signing this form I affirm that the information I have given or will give
to the Department of Social Services is correct.
Signature: __________________________________Date:__________ *
This form must not remain in the client’s TA case Record. It must be forwarded to the DVL for confidential filing if any part of it has been completed.