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Victim Survivor Details
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Was an interpreter used during this assessment?	☐Yes ☐No (If yes, what language):
Country of birth:	Year of arrival in Australia:
Bridging or Temporary Visa?	☐Yes ☐No (If yes, what type):
Language mainly spoken at home:	Service provider client ID:
Emergency contact: Relationship to victim survivor:	Name: Contact Number:

Perpetrator Details
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Relationship to victim survivor:	Service provider client ID:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Further details

Child 1 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Child 2 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Child 3 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Question	Yes	No	Comments (or not known)
Has anyone in your family done something that made you or your children feel unsafe or afraid?
Is there more than one person in your family that is making you or your children feel unsafe or afraid? (Are there multiple perpetrators)
The following risk related questions refer to the perpetrator:
Perpetrator actions	Have they…
	controlled your day-to-day activities (e.g. who you see, where you go) or put you down?*
	threatened to hurt you in any way?
	physically hurt you in any way (hit, slapped, kicked or otherwise physically hurt you)?
SELF-ASSESSMENT	Do you have any immediate concerns about the safety of your children or someone else in your family?
Do you feel safe when you leave here today?
Would you engage with a trusted person or police if you felt unsafe or in danger? (Note: if lack of trust in police is identified risk management must address this)
Further details

*May
indicate an increased risk of the victim being killed or almost
killed (serious risk factors).

NEEDS
AND SAFETY

Needs
assessment

Safety
plan has been completed? (see separate template)

☐Yes
☐No
☐Not
known

Child 4 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Child 5 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known
Child 6 Details^#	^#Separate risk assessment must be completed
Full Name:	Alias:
Date of Birth:	Also known as:
Gender: ☐ Woman/Girl ☐ Man/Boy ☐ Self-described (please specify) ☐ Client preferred not to say ☐ Unknown	Intersex: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown
Transgender: ☐ Yes ☐ No ☐ Client preferred not to say ☐ Unknown	Sexuality: ☐ Same sex/gender attracted ☐ Heterosexual/other gender attracted ☐ Multi-gender attracted ☐ Asexual ☐ None of the above ☐ Client preferred not to say ☐ Unknown
Primary address:	Current Location:
Contact number:	Comments:
Relationship to victim survivor:	Relationship to perpetrator:
Aboriginal and/or Torres Strait Islander ☐ Aboriginal ☐ Torres Strait Islander ☐ Both Aboriginal and Torres Strait Islander ☐ Client preferred not to say ☐ Neither ☐ Not known	CALD ☐ Yes ☐ No ☐ Not known LGBTIQ ☐ Yes ☐ No ☐ Not known People with disabilities ☐ Yes ☐ No ☐ Not known Rural ☐ Yes ☐ No ☐ Not known

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