Assessment & Plan Elements
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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"]
Stress and Safety:
Over the past, week how safe have you felt in your relationship?



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)?
Insulted or talked down to you?
Threatened you with harm?
Screamed or cursed at you?
Threatened or abused your children?

Friends and Family:
If you were hurt, would your friends or family know?
Would they be able to help you?

Emergency Plan:
Do you have a safe place to go in an emergency?
Do you need help in locating a shelter?
Would you like to talk to a counselor about this?

Result - Copy and paste this output:

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