IPV / trafficking screen

HSA-aligned prompts. Not a clinical scale. Use a safe device.

Nothing is stored. Print or Save as PDF if you need a record. Confirm current statutes before you act.

These prompts follow the idea of the Housing Services Act Special Priority elements. They are not a clinical IPV scale and not a CAS investigation.

Safe yes/no prompts (print and fill off-screen if needed)

Are you afraid of someone you live with or recently lived with? ☐ Yes ☐ No ☐ Not now
Have you had to leave a home because of abuse or trafficking? ☐ Yes ☐ No ☐ Not now
Do you need housing that the other person cannot find? ☐ Yes ☐ No ☐ Not now
Is there a worker (VAW, shelter, lawyer, doctor) who can verify without graphic detail? ☐ Yes ☐ No ☐ Not now
Should mail and phone be kept from a particular person? ☐ Yes ☐ No ☐ Not now
Are children or pets at risk if you return? ☐ Yes ☐ No ☐ Not now

If yes to danger: 911 or Assaulted Women’s Helpline 1-866-863-0511. Then the SPP pathway.