Page 84 - Meeting with Children Manual

P a g e | 4 Client Intake Form

Party A File Number ______________________ Colour of Risk_____________

FAMILY SAFETY:

Screening  Female initiated separation Risks  History of controlling
 Male attached to relationship Present  History of violence
 Separation less than 6 months  Threats
 Weapons access
 Police involvement  Weapons use
 Y  Strangulation
 N  Sexual assault
 Physical violence
 Number of callouts: _________  Drug/alcohol
 Suicidal ideation
 Charges:  Use of pets
 AVO Copy on file  Use of children
 Charges copy on file  Stalking
 Conviction copy on file  Monitoring/surveillance
 Mental Health Concenrs


DVSAT  Y Colour  RED
Completed  N  ORANGE
 Attached  YELLOW
 GREEN
Child at Risk  Y ROSH tree  Y Mandatory  Y
Concern  N  N Report  N
 Ref:

© Lorri Yasenik and Jon Graham 2016
Private and Confidential
We acknowledge and pay respect to the traditional owners and custodians of the land on which we work and live.
The Institute of Specialist Dispute Resolution Pty Ltd
ABN 46 105 820 791
PAGE 82