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?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

18   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 have hit you!  I was just joking!)

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

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

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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