Domestic Violence History

Lethality Scale Checklist

Case Name: __________________________

Case No. _____________________________

(circle)

(circle)

Incident

Explanation

Experienced violence as a child

Tells victim she is useless, calls names

Tells victim she cannot get along without him

Refuses the victim to have phone calls or friends

Accuses victim of having affairs

Is excessively jealous or blames victim

Has destroyed personal property (especially those of sentimental value)

Has imprisoned or held victim hostage

Threatened or has threatened suicide or homicide

Has a history of sexual deviance

Is obsessed with victim

Is controlling and resents interference

Disables vehicle to control victim

Is not fearful of consequences

Has made previous suicide attempts

Has history of alcohol abuse

Has acknowledged or reported history of drug use

Has history of psychiatric illness

Has access to weapons

Is faced with divorce or separation

(describe incident)

Victim feels tension build before an incident

Apologizes after assaulting victim

Brings victim gifts and tries to make amends

Promised never to be abusive again

Was involved in a violent relationship with another person

Drinks or uses drugs prior to or during violent incident

Has used a weapon to threaten or assault

Has killed or injured family pets

Has been arrested previously for domestic violence

Has previously engaged in abuse or violence and was not reported

Has engaged in escalating violence

Has assaulted victim while she was pregnant

Has injured victim in the past

Is hostile, angry, out of control

Threatens to injure children

Has abused children in the past

Stalks victim even when there is a No Contact Order

Take number of responses marked Yes and divide by 37. Circle the risk rating below and enter alphabetic value in box below.

VLR
.11
0-4

LR
.24
5-9

LMR
.38
10-14

MR
.51
15-19

VLR = very low risk

LR = low risk
LMR = low to moderate risk
MR = moderate risk
MHR = moderate to high risk
HR = high risk
HEHR = high to extremely high risk
EHR = extremely high risk

MHR HR
HEHR
.65
.78
.91
20-24 25-29 30-34

EHR
1.0
35-37

RISK:

Use discretion with scoring, depending upon circumstances

as a lower number checked yes may still indicate a higher
risk.