| 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
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. |
| Copyright (c) 2010 - theprministries.org - Developed by premiersite.org |
| 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.
“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
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 |
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| 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.
back together again.