Pastoral Resource Ministries, Inc.
This survey will help you decide if you are in an abusive relationship.  It will help you determine
if you need to seek help from a  professional or a Domestic Violence counselor.
 Remember  
You Are Not Alone!  It Is Not Your Fault!
 A Domestic Violence counselor or professional
will help you deal successfully with an abusive relationship.

Instructions:  This is a screening measure to help you determine whether you might be involved
in an abusive relationship that needs attention.  This screening measure is not designed to make a
diagnosis or take the place of a professional consultation.  For each item, indicate the extent to
which it is true, by checking the appropriate box next to the item.

1.  Do you feel anxious or nervous when you are around your partner?

No  __________                      Sometimes __________                      Regularly __________

2.  Do you feel anxious or nervous when you have to relay “bad news” to your partner?

No  __________                      Sometimes __________                      Regularly __________

3.  Do you watch what you are doing in order to avoid making your partner angry or upset?

No  __________                      Sometimes __________                      Regularly __________

4.  Do you feel obligated or coerced into having sex with your partner?

No  __________                      Sometimes __________                      Regularly __________

5. Are you afraid of voicing a different opinion than your partner?

No  __________                      Sometimes __________                      Regularly __________

6.  Does your partner criticize you or embarrass you in front of others?

No  __________                      Sometimes __________                      Regularly __________

7.  Does your partner check up on what you have been doing, and not believe your answers?

No  __________                      Sometimes __________                      Regularly __________

8.   Is your partner jealous, or accuse you of being unfaithful?

No  __________                      Sometimes __________                      Regularly __________

9.   Have you stopped seeing your friends or family because of your partner’s behavior?

No  __________                      Yes __________                       

10. Does your partner’s behavior make you feel as if you are wrong?

No  __________                      Sometimes __________                      Regularly __________

11. Does your partner threaten to harm you physically or make threatening gestures?

No  __________                      Sometimes __________                      Regularly __________

12. Has your partner ever destroyed any belongings or household items?

No  __________                      Yes __________                       

13. Does your partner keep you from going out or doing things that you want to do?

No  __________                      Sometimes __________                      Regularly __________

14. Do you try to please your partner rather than yourself in order to avoid being hurt?

No  __________                      Sometimes __________                      Regularly __________

15.  Do you feel that nothing you do is ever good enough for your partner?

No  __________                      Sometimes __________                      Regularly __________

16. Does your partner say that if you try to leave him or her, you will never see your children again?

No  __________                      Yes __________                      Not applicable __________

17. Does your partner say that if you try to leave he or she will kill him/ herself or you?

No  __________                      Sometimes __________                      Regularly __________

18.  Is there always an excuse for your partner’s behavior?  (The alcohol or drugs made me to it!  
My job is too stressful!  If dinner  
was on time, I wouldn't’t have hit you!  I was just joking!)

No  __________                      Sometimes __________                      Regularly __________

19. Does your partner tell you that he or she will stop beating you when you start behaving yourself?

No  __________                      Yes __________                      

20. Do you lie to your family, friends and doctor about your bruises, cuts and scratches?

No  __________                      Yes __________                      Not applicable __________

Scoring:
The higher your score, the more likely you are in an abusive relationship.
If your score is:
If you answered “regularly”, “sometimes”, or “yes” to:
5 questions or less – domestic violence is unlikely
6 to 10 questions – abuse is possible
10 and over – it is very possible that the relationship has become abusive
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Our goals are to eliminate domestic violence, empower victims, educate the public, and promote partnerships.
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Stop Domestic Violence
One of the best reasons to give to the
“Created to Be Whole” Domestic
Violence Program (CTBWDVP) for
women is to make a difference in the
lives of women.  Every donation to  
this program helps support victim s of
violence and to ensure someone is
available for them in a time of need.
Use a safe computer. Computer use
can be monitored and is impossible
to completely clear. If you are afraid
your Internet and/or computer usage
might be monitored, please use a
safer computer, call your the National
Domestic  Violence Hotline or your
local Domestic Violence Hotline.
Connecticut Hotline
1 (888) 774- 2900
Domestic Violence Survey
Created To Be Whole - Stop Domestic Violence Against Women
Aggressive Behavior
An Outreach Ministry for the Millennium
If you are in immediate danger
call your local police
911
or the
National Domestic Violence
Hotline

1.800.799.SAFE (7233)
1.800.787.3224 (TTY)
Anonymous & Confidential Help
24/7
Stay Safe
This information is not presented as legal advice. It’s for resource purposes for individuals
seeking information on Domestic Violence.  
To contact:
For more information please write or call us at: (860) 916-4613 email: info@theprministries.org
Putting the broken pieces
back together again.