| Not sure how healthy your relationship is? Answer the following questions as honestly as possible. |
| Does your intimate partner ever: | Never | Sometimes | Often |
| 1. Embarrass you, insult you, or put you down in front of other people, in private, to your
children, or on computer networking sites like myspace, or threatens to do so? | | | |
| 2. Look at you, or act in a certain way that’s meant to intimidate or scare you? | | | |
| 3. Try to control what you do, who you see or talk to, how you look, or where you go? | | | |
| 4. Get angry when you make plans on your own, or try to keep you from seeing or talking to
family or friends? Is there a double standard; your partner has freedom to come and go, but
you do not? | | | |
| 5. Cheat on you after agreeing to be monogamous? | | | |
| 6. Take your money, make you ask for money, or refuse to give you money? | | | |
| 7. Try to make all the decisions, big or small? | | | |
| 8. Get jealous over any little thing (or nothing), or get angry if you don’t want to have sex? | | | |
| 9. Call, text, or IM you often to check up on you? | | | |
| 10. Threaten to abandon you, or kick you out whenever they get angry, even over minor things? | | | |
| 11. Threaten to take away or hurt your children (or pets)? | | | |
| 12. Encourage your children to participate in the abuse? | | | |
| 13. Act like the abuse is no big deal, or it’s all your fault, or minimizes, or denies doing it? | | | |
| 14. Destroy or damage property (usually yours)? | | | |
| 15. Lock you in, or out of the house, or a room? | | | |
| 16. Intimidate or threaten you with weapons (or even talk about using weapons)? | | | |
| 17. Shove, grab, or hold you down? | | | |
| 18. Slap, hit, pull hair, kick, or bite you? | | | |
| 19. Threaten suicide if you leave, or try to end the relationship? | | | |
| 20. Threaten to kill you if you leave, or try to end the relationship? | | | |
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