Domestic Abuse Client Survey Form (ID #8501)

I have written this form and survey for people suffering from domestic abuse which impacts family and housing security and even homelessness and is part of a longer-term project to document your common issues and to redesign services from the feedback of those with lived experience. I have been both in these sorts of relationships and have even been homeless as a result, on many occasions. These questions are designed and split into areas which are the most common with regard to the issues.

By completing this you are agreeing to take part in the survey. All reports will be anonymous and strictly confidential with any personal data collected stripped out to protect your identity.

Advocacy Clients. This info is used to assist you with your casework and advocacy and will form part of a report which I will use to help with your specific issue. This is a fact find but out of this situation we can collectively share our experiences, as much as we feel comfortable with and these can help transform services for others in this position. Very much paying it forward!

Any question do let me know!


Daniel Harris

About You

if so please explain briefly just a paragraph or sentence.


Your Wellbeing & Safety

These questions are on a scale of 1= never, 2= not very often, 3= not often, 5= sometimes, 7= often, 8= very often, 9= most days, 10= all the time and so on. Please answer these honestly.


    Controlling behaviour is:
a range of acts designed to make a person subordinate and/or dependent by isolating them from sources of support, exploiting their resources and capacities for personal gain, depriving them of the means needed for independence, resistance and escape and regulating their everyday behaviour.

    Coercive behaviour is:
an act or a pattern of acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten their victim.”

      Psychological abuse involves the regular and deliberate use of a range of words and non-physical actions used with the purpose to manipulate, hurt, weaken or frighten a person mentally and emotionally; and/or distort, confuse or influence a person’s thoughts and actions within their everyday lives, changing their sense.

      Controlling finances, stealing money, coercing someone into debt, restricting/ exploit/sabotaging their partner’s access to money and other resources, such as food, clothing, transportation and a place to live. (from Surviving Economic Abuse)

If so please state who and what has or hasn't happened?



Thank you for for completing this survey.