Domestic Violence Assessment Tool

CLICK HERE to view and use this assessment tool created by Dr. Ramona

Preparing to Leave Safety Plan

Please visit to begin preparing your safety plan. This free assessment provides 20 questions, along with a calendar that can be used to document abusive incidents. This is an extremely important step in preparing to leave. Because violence could escalate when a victim tries to leave, here are some things to keep in mind before you leave:

  • Keep any evidence of physical abuse, such as pictures of injuries.
  • Keep a journal of all violent incidences, noting dates, events, and threats made, if possible. Keep your journal in a safe place.
  • Know where you can go to get help. Tell someone what is happening to you.
  • If you are injured, go to a doctor or an emergency room and report what happened to you. Ask that they document your visit.
  • Plan with your children and identify a safe place for them to go, such as a room with a lock or a friend’s house where they can go for help. Reassure them that their job is to stay safe, not to protect you.
  • Contact your local shelter and find out about laws and other resources available to you before you have to use them during a crisis. has state by state legal information.
  • Acquire job skills or take courses at a community college as you can.
  • Try to set aside money or ask friends or family members to hold money for you.

When You Are Leaving Safety Plan

Make a plan for how and where you will escape quickly. You may request a police escort when you leave. Use the following list of items as a guide for what you need to bring with you. You can also call 1-800-799-SAFE (7233) to speak with an advocate who can help you come up with a personalized safety plan for leaving.

  1. Identification
  • Driver’s license
  • Birth certificates for you and your children
  • Social security cards
  1. Legal Papers
  • Protective order
  • Copies of any lease or rental agreements or the deed to your home
  • Car registration and insurance papers
  • Health and life insurance papers
  • Medical records for you and your children
  • School records
  • Work permit/green card/visa
  • Passport
  • Divorce and custody papers
  • Marriage license
  1. Emergency Numbers
  • Your local police and/or sheriff’s department
  • Your local domestic violence program or shelter
  • Friends, relatives, and family members
  • Your local doctor’s office and hospital
  • County and/or district attorney’s office
  1. Other
  • Money and/or credit cards (in your name)
  • Checking and/or savings account books
  • Financial information
  • Medications
  • Extra set of house and car keys
  • Valuable jewelry
  • Pay-as-you-go cell phone
  • Address book
  • Pictures and sentimental items
  • Several changes of clothes for you and your children

After You Have Left Safety Plan

You should have a safety plan to ensure your continued safety after you have left an abusive relationship. Here are some safety precautions to consider:

  • Change your locks and phone number.
  • Call the telephone company to request caller ID. Ask that your phone number be blocked so that if you call anyone, neither your partner nor anyone else will be able to get your new, unlisted phone number.
  • Change your work hours and the route you take to work.
  • Change the route you take to transport your children to school or consider changing your children’s schools.
  • Alert school authorities of the situation.
  • If you have a restraining order, keep a certified copy of it with you at all times. Call law enforcement to enforce the restraining order and give copies of the order to friends, employers, neighbors, and schools, along with a picture of the offender.
  • Consider renting a post office box or using the address of a friend for your mail (be aware that addresses are on restraining orders and police reports, and be careful to whom you give your new address and phone number).
  • Reschedule appointments that the offender is aware of.
  • Use different stores and frequent different social spots.
  • Alert neighbors and request that they call the police if they feel you may be in danger.
  • Replace wooden doors with steel or metal doors. Install security systems if possible.
  • Install a motion sensitive lighting system.
  • Tell people you work with about the situation and have your calls screened by one receptionist if possible.
  • Explain your situation to people who take care of your children or drive them / pick them up from school and activities. Provide them with a copy of the restraining order.

The above material was adapted from the National Center for Victims of Crime,