Lori B. Girshick, Ph.D.

(Give prospective client checklist of behaviors to fill out first)

(1)  How did you find out about this service?

(2)  What led you to call now?

(3)  How long have/had you been in the relationship?

(4)  When was the first abusive incident?  (Ask for a specific description, who did what when.)  How did the incident end?

(5)  How often did these incidents occur?  (Look for increased frequency over time, increased severity of violence and lethality.)

(6)  What would you say was the worst incident that occurred?

(7)  When was the last or most recent incident?  What specifically happened?

(8)  Have the police ever been called?  What happened?

(9)  Did you or your partner ever seek medical treatment for injuries resulting from the abuse?  What happened?

(10)  Have you sought other assistance before?  From who/where?  What happened?

(11)  Have friends or relatives expressed concern or intervened?  What did they say/do?  What do you think about what they said/did?

(12)  How do/did you and your partner resolve conflict?

(13)  What would happen if you did something your partner didn't want you to do?

(14)  How did/do you feel about yourself after an abusive incident?  How did/do you feel about your partner?

(15)  Have you seen a mental health professional?  Are you presently under a doctor's care?

(16)  How would you describe your mental health?  Your physical health?

(17)  Are you presently using any drugs or alcohol?

(18)  What would your goals be from utilizing this service?

(19)  What is your abuser's name?  Will you describe her?  Do you have a picture you could show us?

(20)  How can we reach you by phone safely?  (At home or work?)  Are there certain times when we shouldn't call?