Domestic Violence Risk Assessment

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Women can answer the following questions to get a sense of their
likelihood of experiencing, or already being the victim of, domestic violence.

Results:
The more often you answered “Yes” to the above questions, the greater the chance that you will become, or that you already are, the victim of domestic violence. If you answered “Yes” to questions above, consider discussing domestic violence with one of our Reliant Behavioral Health and Community Services Clinical Team Members. If you are in immediate danger and do not feel safe please call 911, 211, and or visit your local emergency room for assistance.

电子邮件地址 *

Full Name *

Phone Number *

INSTRUCTIONS: This scale is designed for your personal use. There are no right or wrong answers. Usually your first response is the best. Please print these pages out for your personal use. You may also bring this assessment with you to your appointment and discuss the findings during your visit.

Has your partner threatened you physically?

Yes

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Has your partner struck you, pushed you, grabbed you roughly, thrown you, or choked you?

Yes

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Have you sustained physical injury from your partner?

Yes

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Does your partner blame you for any injury that you might have sustained from him or her?

Yes

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Has your partner pressured you into any sexual activity that made you feel uncomfortable or degraded?

Yes

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Has your partner forced you to have sex?

Yes

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Has your partner ever raped or attempted to rape you?

Yes

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Does your partner yell at you or call you names?

Yes

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Does your partner embarrass you in front of others?

Yes

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Do you feel belittled regularly by your partner?

Yes

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Does your relationship otherwise feel conflicted or unstable?

Yes

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Were you or your partner the victim of, or otherwise experience, any pattern of abuse as a child or young adult?

Yes

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Does your partner seem to have low self-esteem?

Yes

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Does your partner have a rigid belief in male/female roles?

Yes

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Is your partner destructive to your possessions or your physical environment?

Yes

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Does your partner become aggressive when drunk or using drugs?

Yes

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Does your partner use drunkenness or drug use as an excuse for behaving in an aggressive manner towards you?

Yes

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Does your partner blame you when he or she behaves poorly?

Yes

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Do you find yourself denying the nature of aggressive incidents after they occur?

Yes

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Do you have a habit of finding, or looking for, a way to blame yourself for your partner’s behavior?

Yes

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Does your partner try to limit your relationship with family and friends?

Yes

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Are you isolated from family and friends?

Yes

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Are you disabled?

Yes

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Do you feel that your partner is overly controlling of your time, attention, actions, words, activities, or whereabouts?

Yes

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Does your partner sometimes seem obsessed with you or extremely jealous of you?

Yes

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Does your partner seem, hostile, angry, or furious often?

Yes

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Has your partner previously been involved with incidents of violence?

Yes

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Does your partner’s aggressive behavior seem to occur in cycles?

Yes

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Has your partner every threatened to hurt himself or herself to punish you?

Yes

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Is your partner hurtful toward – or ever threaten to hurt – children, pets, or others?

Yes

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Does your partner make you overly or directly dependent for all money?

Yes

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Do you worry about what your partner would do if you broke up with him or her?

Yes

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Have you ever felt stalked by your partner?

Yes

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Have you previously been in an abusive relationship?

Yes

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Do you have plans to end this relationship?

Yes

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Is your partner aware of your plans to end this relationship?

Yes

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Do you experience physical or mental affects such as anxiety, depression, fatigue, or stomach or other gastrointestinal pain or problems that you feel are might be a result of stress related to your partner’s behavior toward you?

Yes

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您回复的副本将通过电子邮件发送到您提供的地址。

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