<p>Staying Safe: these are the self-assessment questions taken from the Staying Safe section. </p><p>You can print out these questions, complete them and then use the answers to describe your situation when you look for support. They will help Police or other support agencies to understand what is happening. You can complete them as often as you want but please sign and date every page so that you can monitor and show changes over time</p><p>Feelings: Think carefully and try to work out how frightened you are now. </p><p>Trust your feelings. If you are very scared please do not feel ashamed – it may save your life to realise that you are in grave danger and to take action to increase your safety.</p><p>Yes/ No What do you fear may happen Are you very scared now</p><p>Are you a bit scared now but more worried about the future Are you also scared for others close to you</p><p>What are the possible risks</p><p>Facts: Think carefully about the person who is targeting you.</p><p>Assess the risk of this unwanted behaviour YES/NO</p><p>Have they behaved like this before to you</p><p>Signed By: Date: Have they behaved like this before to anyone else</p><p>Have they ever damaged anything of yours on purpose</p><p>Have they ever damaged anything belonging to anyone else on purpose Do they try to find you at home more than 3 times per week</p><p>Do they try to find you at work more than 3 times per week </p><p>Do they hang around where they think you might be. How often</p><p>Have they made any threats of physical or sexual violence against you</p><p>Have they been violent to or threatened violence against people close to you Have they contacted anyone else to try to find information about you </p><p>Have they contacted anyone else to get them to pass messages to you</p><p>Do they use drugs</p><p>Do they use alcohol</p><p>Have they ever had treatment for mental illness</p><p>Have they ever threatened suicide or self-harm</p><p>Have they ever been emotionally abusive or violent to anyone in the past Have they ever been cruel to an animal</p><p>Are the unwanted things they are doing getting more serious or frightening Are the unwanted things they are doing becoming more frequent</p><p>Every single one of the questions above is an indicator of increased risk of harm. Any YES answer means risk is present.</p><p>Signed By: Date: Do you have additional risk factors at the moment?</p><p>Do you also have additional risk factors: YES/NO</p><p>Any Illness or disability</p><p>Impaired sight or hearing</p><p>Are you Pregnant</p><p>Are you in an isolated location of home or workplace</p><p>Do you have regular places where you have to be, at regular times – e.g. work/school or regular routines and appointments e.g. hospital, hairdresser, classes, clubs</p><p>Any other?</p><p>Now can you write down what you are afraid they might do to you or to someone else? Here is a list that might help you to get started:</p><p>Unwanted Behaviour YES / NO</p><p>Phone or text</p><p>Email, Twitter or Facebook you or your contacts</p><p>Follow you or people close to you</p><p>Spy on you</p><p>Hurt you or people close to you – your children or family</p><p>Hurt or kill your family pets</p><p>Make trouble for you at work </p><p>Use ways of tracking you </p><p>Break into your home and hurt you there</p><p>Signed By: Date: Interfere with your car so that it is unsafe</p><p>Push you to a mental breakdown</p><p>Push you to suicide</p><p>Kill you, your children or someone close to you</p><p>Who is being affected by this unwanted behaviour Clearly you are – or you would not have got this far. But think who else might come to harm. Remember on average 27 people close to someone who is being stalked are also affected or harmed by the stalking.</p><p>Write down their names Have you told then? YES / NO Someone who tries to protect you</p><p>Someone you care about, just to get at you</p><p>Your family, parents, brothers, sisters</p><p>Your children</p><p>Someone who just happens to be near you, in the wrong place at the wrong time e.g. at work</p><p>Colleagues or friends who do not cooperate by giving information or refuse to take messages Other</p><p>Signed By: Date: </p>