Ask the client:
“Is there a person in your life who might do any of
the following:”
1. Physically hurt you or threaten to hurt you or someone
else close to you?
�Yes � No � Don’t know
2. Check up on you or follow you?
� Yes � No � Don’t know
3. Make all or most decisions for you?
� Yes � No � Don’t know
4. Withhold money for food, clothing, or other needs?
� Yes � No � Don’t know
5. Tell you who you can see or talk to?
� Yes � No � Don’t know
6. Tell you where you can go?
� Yes � No � Don’t know
