MASIC-S Step 1 of 9 11% Date of Interview Internal Matter Number (optional; not the actual case number): PARTY NARRATIVE (RECOMMENDED BUT OPTIONAL) (Opportunity for Interviewee to Explain their Situation in their Own Words if the Screening is Done at the Start of the Client’s Interview) Example Script: I will be asking you some questions today. First, I would like to ask you to tell me, in your words, what brings you to us/me? (Note: Elicit brief narrative about why the client has come to meet with you.)NotesMASIC-S INTRODUCTION (REQUIRED) Required Script: I am now going to ask you a series of questions about your relationship with [the other party], who we understand is or was a significant other or spouse of yours. These questions relate to [the other party’s name] and not other people, but let us know if any other people are doing the kinds of things we are asking about.] Your responses to these questions will be confidential. They will NOT be shared with the court or [the other party]. Your responses will only be used to help you and us/me decide how to proceed in this case. You may wonder about some of the questions you will now be asked, but it is helpful to think of this like a visit to the doctor’s office. There, you are often asked questions that may not seem important to you or may not seem to apply to you but are important to the doctor. The questions you will be asked now are important for deciding what kind of in court or out of court process would work well for you. So please answer the following questions to the best of your ability. In answering these questions, I am asking about things that [the other party] may have done during a conflict, disagreement, fight, or in anger, or to scare you or hurt you, but NOT while joking around. It is also important to let us/me know as you answer each question, whether [the other party] would say that you did what is being asked about to [the other party]. [Note to the screener: You or your colleague should take careful notes off the MASIC-S form of all information about what the other party will say about the client’s perpetration of abuse.] Section 1All questions below are REQUIRED except for some follow-up questions that are marked "Recommended but optional" Did [the other party] ever (whether or not while living with you)...1. Forbid you to go out without [him/her/them]? Yes No Don't Know 2. Drive dangerously to scare you, or when angry at you? Yes No Don't Know 3. Physically abuse or threaten to abuse pets to scare or hurt you, or when angry at you? Yes No Don't Know 4. Threaten to hurt someone you care about? Yes No Don't Know 4A. Please describe: (recommended but optional)5. Threaten to hurt you? Yes No Don't Know 5A. Please describe: (recommended but optional)6. Threaten to kill you? Yes No Don't Know 6A. Please describe: (recommended but optional) Required Script: 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. Please also remember to let us/me know as you answer each question, whether [the other party] would say that you did what is being asked about to [the other party].7. Hold you down, pinning you in place? Yes No Don't Know 8. Scratch you, or pull your hair, or twist your arm, or bite you? Yes No Don't Know 8A. Please describe (recommended by optional)9. Slap you? Yes No Don't Know 10. Hit or punch you? Yes No Don't Know 11. Kick or stomp on you? Yes No Don't Know 12. Try to choke/strangle you or cut off your breathing? Yes No Don't Know 12A. Please describe: (recommended but optional)13. Burn you with something? Yes No Don't Know 14. Use a weapon against you or threaten you with a weapon or something like a weapon? Yes No Don't Know 14A. Please describe (include what kind(s) of weapons(s) or object(s)): (recommended but optional)15. Demand or insist that you engage in sexual activities against your will? Yes No Don't Know 16. Physically force you to engage in sexual activities against your will? Yes No Don't Know 17. 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 17A. Please describe: (recommended but optional)18. 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:19. 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 19A. Please describe (include when and fear for whom): (Recommended but optional)19B. 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 20. 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 20A. Please describe (include when and a description of serious injuries/the worst injury): (recommended but optional)20B. 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. 21. Have any of these behaviors happened in the past year? Yes No Don't Know 21A. Please describe (include which behaviors and when): (Recommended but optional)21B. REQUIRED FOLLOW UP: Has the physical violence increased in severity or frequency in the past year? Yes No 22. 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 23. Is or was [the other party] successful in controlling your activities, your work, your contact with family and friends, or your access to money or financial information? Yes No Don't Know 24. Are you afraid that [the other party] will harm you during or after a court or settlement process because of what you say or do in that process? Yes No Don't Know MASIC-S Questions - SECTION 3RECOMMENDED BUT OPTIONAL Do you have any of the following concerns about [the other party]? 25. Overuse of alcohol, prescription medications, or other substances? Yes No Don't Know 25A. Please tell me more about your concern: (Recommended but optional)26. Illegal drug use? Yes No Don't Know 26A. Please tell me more about your concern: (Recommended but optional)27. Child abuse and/or neglect concerns? Yes No Don't Know 27A. 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)]28. Any criminal history? Yes No Don't Know 28A. Please tell me more about your concern: (Recommended but optional)29. Do you have any other concerns about [the other party] that could affect your physical safety [if there are children: and/or the physical safety and emotional wellbeing of your children]? [If your client asks what this question means, offer suggestions including “other family members,” “relatives,” “significant others,” “health concerns of anyone involved,” “smoking,” etc. Your client may respond with any concerns they believe are relevant to share, including “mental health problems.”] Yes No Don't Know 29A. Please tell me more about your concern: (Recommended but optional) MASIC-S QUESTIONS-SECTION 4 (REQUIRED) Ask all parties the following question (regardless of whether Sections 2 and/or 3 were completed)30. Do you think there is any reason why you should not initiate a court case against [the other party]? Yes No Don't Know 30A. Required follow-up: Please explain:31. Are there any current or past protective orders, restraining orders, or orders of protection issues against [the other party]? Yes No Don't Know 31A. Required follow-up: Please explain:32. As a result of the questions you have been asked, do you have concerns that you would like to share about how to proceed in this case? Yes No Don't Know 32A. Required follow-up: Please explain:I understand that Mediate.com/ODR.com will provide me with a link to a downloadable PDF version of the information I have inputted into this MASIC-S form once I have submitted this form to Mediate.com/ODR.com and made the required certification.(Required) I certify I understand that Mediate.com/ODR.com will provide me with a link to a downloadable PDF version of the information I have inputted into this MASIC-S form once I have submitted this form to Mediate.com/ODR.com and made the required certification. I certify that no identifiable information has been inputted into this confidential MASIC-S form. I further certify that I have not inputted any actual case numbers into this form, and I have not included any case or personal identifying information about the case or the parties in the case, including names, birth dates, social security numbers, locations, and the like.(Required) I certify I certify that no identifiable information has been inputted into this confidential MASIC-S form. I further certify that I have not inputted any actual case numbers into this form, and I have not included any case or personal identifying information about the case or the parties in the case, including names, birth dates, social security numbers, locations, and the like. I understand that my ONLY opportunity to download the PDF version of this completed form will be after I click submit below and receive the link, and I will NOT be able to download the PDF after I leave the website. I also understand that once I download the PDF version of this form and leave the website, I will have the only copy of the information on this MASIC-S form.(Required) I certify I understand that my ONLY opportunity to download the PDF version of this completed form will be after I click submit below and receive the link, and I will NOT be able to download the PDF after I leave the website. I also understand that once I download the PDF version of this form and leave the website, I will have the only copy of the information on this MASIC-S form.
