HIT-SAFE

Stress and Safety:
Over the past, week how safe have you felt in your relationship? 
[textarea name="safe" default=" "]


[comment memo="Using a scale from 1-5, where 1 is never and 5 is very frequently"]
Afraid or Abuse:
In the past week how often has your partner...
Physically hurt you (e.g. pushed, slapped, hit, kicked, punched)? [checkbox name="hurt" value="1|2|3|4|5"]
Insulted or talked down to you? [checkbox name="insult" value="1|2|3|4|5"]
Threatened you with harm? [checkbox name="threaten" value="1|2|3|4|5"]
Screamed or cursed at you? [checkbox name="scream" value="1|2|3|4|5"]
Threatened or abused your children? [checkbox name="children" value="1|2|3|4|5"]

Friends and Family:
If you were hurt, would your friends or family know? [checkbox name="know" value="Yes|No|NA"]
Would they be able to help you? [checkbox name="help" value="Yes|No|NA"]

Emergency Plan:
Do you have a safe place to go in an emergency? [checkbox name="place" value="Yes|No|NA"]
Do you need help in locating a shelter? [checkbox name="shelter" value="Yes|No|NA"]
Would you like to talk to a counselor about this? [checkbox name="counselor" value="Yes|No|NA"]