be conducted with all female clients to determine if they are being abused by their intimate partners.
Universal screening of female clients for domestic violence should be part of all intakes, especially since conventional clinical questions may miss important indicators of abuse and battering. Most forms of domestic violence and abuse are chronic in nature and there are many factors that influence the nature of the clinical picture seen, such as the specific acts and temporal pattern of her partner's abuse, the victim's psychological make-up, the victim's developmental stage, and the availability of external resources. Direct assessment for domestic violence is essential to understanding the clinical presentation.
b.Mental health providers should routinely screen all child clients for the presence of adult domestic violence and for concurrent child abuse and neglect.
Frequently, the presenting problems of children are related to or a result of domestic violence, including a wide variety of somatic, behavioral, or emotional problems. Proper and early identification of domestic violence as a factor helps to ensure both appropriate diagnoses and treatment plans.
c.For clients identified as victims, mental health providers should elicit and document complete health histories, including trauma histories. With the victim's consent, this should include obtaining copies of relevant medical records from other sources. Providers should maintain thorough, objective, and accurate case records.
Information obtained from the victim, as well as any pertinent observations, should be carefully and fully entered into the client record. Any future or pending legal proceedings might very well draw on the information recorded in the case record. The failure to document the abuse may be used by the perpetrator to deny its existence, or the provider may be held liable for failing to recognize the abuse and respond to the victim's complaints. Client statements are best recorded through the use of direct quotations, when possible. Injuries should be either photographed, or detailed in careful schematic drawings. The fact of abuse and any sequelae noted should become part of the master problem list.
While thorough and accurate case recording is necessary, be alert to the potential harmful uses of the information in the case record, such as an abuser using a partner's mental health diagnosis as evidence of the victim's unfitness as a custodial parent.