Items:

Psychological violence

*Has he insulted you or made you feel bad about yourself?

*Has he belittled or humiliated you in front of other people?

*Has he done things to scare or intimidate you on purpose?

*Has he threatened to hurt you or someone you care about?

Physical violence

*Has he slapped you or thrown something at you that could hurt you?

*Has he pushed or shoved you?

*Has he hit you with his fist or with something else that could hurt you?

*Has he kicked you, dragged you or beaten you up?

*Has he choked or burnt you on purpose?

*Has he threatened to use or actually used a gun, knife or other weapon against you?

Sexual violence

*Has he physically forced you to have sexual intercourse when you didn't want to?

*Did you ever have sexual intercourse when you didn't want because you were afraid of what he might do?

*Has he forced you to do something sexual that you found degrading or humiliating?

Response Options:

Yes

No