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HTML BlockAll 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]?1
Drive dangerously to scare you, or when angry at you?1
Physically abuse or threaten to abuse pets to scare or hurt you, or when angry at you?0
Threaten to hurt someone you care about?0
Threaten to hurt you?0
Threaten to kill you?1
Please Describe: (Recommended but optional)

this was bad

HTML BlockPlease 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?0
Scratch you, or pull your hair, or twist your arm, or bite you?0
Slap you?0
Hit or punch you?0
Kick or stomp you?0
Try to choke/strangle you or cut off your breathing?0
Burn you with something?0
Use a weapon against you or threaten you with a weapon or something like a weapon?0
Demand or insist that you engage in sexual activities against your will?0
Physically force you to engage in sexual activities against your will?0
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?0
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?0
HTML BlockNow 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?0
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?0
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?0
Does or did [the other party] act extremely jealous, or frequently check up on where you’ve been or who you’ve been with?0
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?0
Are you afraid that [the other party] will harm you during or after the mediation because of what you say or do in mediation?0

Do you have any of the following concerns about [the other party]?
Overuse of alcohol or prescription medications?0
Illegal drug use?0
Mental health problems?0
Child abuse and/or neglect concerns?0
Any criminal history?0
HTML BlockAsk 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?0
Are there any current or past protective orders, restraining orders, or orders of protection issues against [the other party]?0
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?0