Domestic Violence Questionnaire
Complete Name *
Please write your full legal name that you are using with your attorney:
Your answer
Check the box of all that apply to you currently
Domestic Violence:
Verbal and Emotional Abuse Questions
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about verbal or emotional abuse experiences (optional)
Your answer
Physical Abuse
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about physical abuse experiences (optional)
Your answer
Sexual Abuse
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about sexual abuse experiences (optional)
Your answer
Social Control
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about social control during your relationship (optional)
Your answer
Economic Abuse
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about economic abuse (optional)
Your answer
Manipulation of Children
Please check all of the following that you have suffered from your ex-partner
Comments or additional details about manipulation or abuse of children (optional)
Your answer
Additional Questions
Please check all of the following that you have suffered from your ex-partner
Tell Me About How Much You Experience The Following:
1. Repetitive, unwanted, and disturbing memories of a past stressful incident or event
2. Bad dreams or nightmares related to a past stressful event
3. Suddenly feeling as though you are reliving a past stressful experience, almost as if it were really happening to you again
4. Feeling very upset when something/someone reminds you of a stressful experience
5. Upon thinking about a past stressful experience, you have felt strong physical sensations, such as trembling, sweaty hands, shortness of breath, racing heartbeat, etc.
6. Avoiding talking or thinking about past traumatic or stressful experiences
7. Avoiding people, avoiding places, avoiding situations, avoiding certain objects, or avoiding activities that provoke memories of a past stressful experiences
8. Having difficulty remembering important parts of a past stressful experience (blocked or fragmented memories)
9A. Having strong negative beliefs about yourself, such as "I am bad" or "There is something wrong with me"
9B. Having strong negative believes about other people in the world, such as "no one can be trusted" *
9C. Having strong negative beliefs about the world, such as, "the world is completely dangerous" *
10A. Blaming yourself for causing the stressful experiences, or what happened afterwards *
10B. Blaming someone else for the stressful experiences, or what happened afterwards
11. Having strong negative feelings, such as fear, horror, anger, guilt, or shame
12. You have lost interest in activities that you used to enjoy
13. Feeling distant or cut-off from other people (isolated, lonely, disconnected, etc)
14. Trouble experiencing positive feelings (feeling unable to feel happiness)
15. Irritable behavior, angry outbursts, or acting aggressively
16. Taking too many risks or doing things that could cause you harm (ex. fast driving, excessive drinking, etc.)
17. Being super alert, watchful of your surroundings, or on guard
18. Feeling easily startled or jumpy
19. Difficulty concentrating
20. Trouble with falling asleep or trouble with staying asleep (waking up in the middle of the night)
Now, think about how you feel in a typical week, over that last month or so
How many days per week, on average, do you feel:
1. I have no interest or pleasure in doing things
2. I feel down, depressed, or hopeless
3A. I have trouble with falling asleep, staying asleep, or both
3B. I sleep too much (in excess)
4. I feel tired and have very little energy
5A. I lose my appetite and don't want to eat anything
5B. I overeat in excess
6. I feel bad about myself, feel like a failure, and criticize myself
7. I have problems concentrating, and cannot focus
8A. I talk slowly and move slowly, and other people have noticed
8B. I feel fidgety, and restless. I move fast, talk fast, and other people have noticed
9. I would be better off dead, or of hurting myself in some way
Please Answer YES or NO to Every Question *
NO
YES
I want to die
I have a specific plan to harm myself, and know how I could do it
I have banged my head against a wall to hurt myself
I have punched myself on purpose.
I have attempted to commit suicide, via taking pills, cutting, hanging, consuming poison, suffocation, etc.
I am planning to hurt someone else
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This form was created inside of East Bay Area Therapy.