MASIC - Party Evaluation Form Screener document Step 1 of 7 14% MASIC-SIf you have an internal case number, you may enter it here: (optional) All questions below are REQUIRED except for some follow-up questions that are marked "Recommended but optional" A. Did [the other party in this case] ever (whether or not while living with you)...Forbid you to go out without [him/her/them]? Yes No Don't Know Drive dangerously to scare you, or when angry at you? Yes No Don't Know Physically abuse or threaten to abuse pets to scare or hurt you, or when angry at you? Yes No Don't Know Threaten to hurt someone you care about? Yes No Don't Know Please Describe: (Recommended but optional)Threaten to hurt you? Yes No Don't Know Please Describe: (Recommended but optional)Threaten to kill you? Yes No Don't Know Please Describe: (Recommended but optional) Please remember that all questions concern things that [the other party] ever, whether or not while living with you, may have done during a conflict, disagreement, or fight, or in anger, or to scare or hurt you, but NOT while joking around.Hold you down, pinning you in place? Yes No Don't Know Scratch you, or pull your hair, or twist your arm, or bite you? Yes No Don't Know Slap you? Yes No Don't Know Hit or punch you? Yes No Don't Know Kick or stomp you? Yes No Don't Know Try to choke/strangle you or cut off your breathing? Yes No Don't Know Please Describe: (Recommended but optional)Burn you with something? Yes No Don't Know Use a weapon against you or threaten you with a weapon or something like a weapon? Yes No Don't Know Please describe (include what kind(s) of weapons(s) or object(s)): (Recommended but optional)Demand or insist that you engage in sexual activities against your will? Yes No Don't Know Physically force you to engage in sexual activities against your will? Yes No Don't Know Follow or spy on you, destroy your property, or try to contact you against your will or communicate in a way that made you feel frightened or harassed, for example, by unwanted phone calls, leaving you threatening notes, leaving threatening messages on your voicemail, sending you threatening text messages, or posting threatening messages on social media? Yes No Don't Know If yes, please describe: (Recommended but optional)Stand outside your home, school, workplace, or other places where [he/she/they] had no business being, and in a way that made you feel frightened or harassed? Yes No Don't Know Now consider the questions you just answered, or similar kinds of things:As a result of [the other party]’s behaviors, did you ever feel fearful, scared or afraid of physical harm to yourself or to others? Yes No Don't Know Please describe (include when and fear for whom): (Recommended but optional)REQUIRED FOLLOW UP: As a result of the other party’s behaviors, do you CURRENTLY feel fearful, scared or afraid of physical harm to yourself or to others? Yes No As a result of [the other party]’s behaviors, have you ever received any physical injury from a scratch, small bruise, or swelling to a major wound, other severe injury, or permanent damage to you? Yes No Don't Know please describe (include when and a description of serious injuries/the worst injury): (Recommended but optional)REQUIRED FOLLOW UP: did you receive a severe injury such as a major wound, severe bleeding, burn, being knocked out, or a permanent injury such as blindness, loss of hearing, disfigurement, or chronic pain? Yes No MASIC-S QUESTIONS-SECTION 2 If “Yes” to any of the items in Section 1 above, then Section 2 is REQUIRED. If “No” to all questions in Section 1, then you may skip to Section 3. However, according to your clinical judgment, you may also complete Section 2. Have any of these behaviors happened in the past year? Yes No Don't Know Please describe (include which behaviors and when): (Recommended but optional)REQUIRED FOLLOW UP: has the physical violence increased in severity or frequency in the past year? Yes No Does or did [the other party] act extremely jealous, or frequently check up on where you’ve been or who you’ve been with? Yes No Don't Know Is or was [the other party] successful in controlling your activities, including work, your contact with family and friends, or your access to money or financial information? Yes No Don't Know Are you afraid that [the other party] will harm you during or after the mediation because of what you say or do in mediation? Yes No Don't Know MASIC-S QUESTIONS-SECTION 3 RECOMMENDED BUT OPTIONAL Do you have any of the following concerns about [the other party]? Overuse of alcohol or prescription medications? Yes No Don't Know Please tell me more about your concern: (Recommended but optional)Illegal drug use? Yes No Don't Know Please tell me more about your concern: (Recommended but optional)Mental health problems? Yes No Don't Know Please tell me more about your concern: (Recommended but optional)Child abuse and/or neglect concerns? Yes No Don't Know Please tell me more about your concern: (Recommended but optional)[Note to screener: we recommend that follow-up include whether there has been involvement with the Department of Child Services (DCS)]Any criminal history? Yes No Don't Know Please tell me more about your concern: (Recommended but optional) Ask all parties the following question (regardless of whether Sections 2 and/or 3 were completed) "As a reminder, mediation is a confidential settlement process that takes place outside of court. Mediation may happen with the parties communicating directly with each other in the presence of the mediator, or with each party meeting privately with the mediator and communicating with the other party or parties through the mediator. [At this point the screener should explain how mediation is done in their program.] Not all cases, however, go through the mediation process. I [or the mediation program] will determine whether mediation will take place in your case, and if mediation will take place, how it will be conducted. I have a few more questions to help make these decisions."Do you think there is any reason why you should not participate in this mediation? Yes No Don't Know Required follow-up: Please explain:Are there any current or past protective orders, restraining orders, or orders of protection issues against [the other party]? Yes No Don't Know Required follow-up: Please explain:As a result of the questions you have been asked, do you have concerns that you would like to share about mediating or the mediation process? Yes No Don't Know Required follow-up: Please describe:
