DV Screening Questionnaire

1 – Never
The behavior has not happened.

2 – Rarely
The behavior has happened once or twice.

3 – Sometimes
The behavior occurs occasionally (e.g., monthly).

4 – Often
The behavior occurs regularly (e.g., weekly).

5 – Very Frequently
The behavior occurs multiple times per week or daily, and is a consistent pattern in the relationship.

Sign in to Google to save your progress. Learn more
Would you like your answers reviewed by an attorney?  *
If yes, please enter the first three letters of your Last name, the first two letters of your first name, and today's date. Ex: HansLe052925 *
Have you filled out the Pre-Consult Form? (If not, please find the link on my website and fill that out also.)
Has he/she ever used a weapon against you or threatened you with a weapon? *
Has he/she threatened to kill you or your children? *
Do you think he/she might try to kill you? *
Does he/she own weapons? *
Has he/she ever used a weapon to threaten to harm themselves? *
Called you names, demean, criticize, belittle, or humiliate you? *
Never
Very Frequently
Tried to keep you from doing something you wanted to do (example: going out with friends, going to meetings) *
Never
Very Frequently
Prevented you from having money for your own use? *
Never
Very Frequently
Thrown something at you (or your children)? *
Never
Very Frequently
Threatened to throw something at you (or your children)? *
Never
Very Frequently
Hit, kick, punch, slap, or shake you (or your children)?
Never
Very Frequently
Clear selection
Threaten to hit, kick, punch, slap, or shake you (or your children)? *
Never
Very Frequently
Pushed, grabbed or shoved you (or your children)? *
Never
Very Frequently
Put down your family or friends? *
Never
Very Frequently
Prevented you from seeing or speaking to your family or friends? *
Never
Very Frequently
Put you on an allowance? *
Never
Very Frequently
Used your children to threaten you (example: told you that you would lose custody, said he or she would leave town with the children)? *
Never
Very Frequently
Became very upset with you because dinner, housework, or laundry was not ready when he wanted it or done the way he thought it should be? *
Never
Very Frequently
Said things to scare you (example: told you something bad would happen, threatened to commit suicide)? *
Never
Very Frequently
Made you do something humiliating or degrading (example: begging for forgiveness, having to ask his permission to use the car or do something)? *
Never
Very Frequently
Violated your privacy (examples: listened to your phone calls, checked the mileage on your car, called you repeatedly at work)? *
Never
Very Frequently
Drove recklessly when you/your children were in the car (either intentionally to scare you or because he was angry/upset at you)? *
Never
Very Frequently
Pressured you to have sex in a way that you didn’t like or want? *
Never
Very Frequently
Stopped you or tried to stop you from going to work or school? *
Never
Very Frequently
Threw, hit, kicked, or smashed something? *
Never
Very Frequently
Physically forced you to have sex? *
Never
Very Frequently
Coerced you to have sex by withholding affection, money, or other essentials or by threatening you? *
Never
Very Frequently
Threatened to kidnap/take the children? *
0-N/A 1-Never
Very Frequently
Coerced you to have sex by withholding affection, money, or other essentials or by threatening you? *
Never
Very Frequently
Do you feel like you need his/her permission to do basic things like go out, spend money, or make phone calls? *
Never
Very Frequently
Choked or strangled you? *
Never
Very Frequently
Destroyed your property? *
Never
Very Frequently
Hurt or threaten to hurt/harm pets? *
Never
Very Frequently
Prevented you from leaving, calling for help, or accessing medical care ? *
Never
Very Frequently
Monitored or stalked you in person or electronically? *
Never
Very Frequently
Putting a tracking device in your vehicle or on your phone without your knowledge? *
Never
Very Frequently
Intentionally prevented you for having transportation? *
Never
Very Frequently
Threatened to report you to CPS, immigration, or other authorities to gain control?   *
Never
Very Frequently
Took control of or prevented you access to identity documents (driver's license, passport, etc.)?   *
Never
Very Frequently
Blame you for his/her anger, stress, or abusive behavior? *
Never
Very Frequently
Told you what you can or can’t wear, eat, or do in your free time ? *
Never
Very Frequently
Use guilt, threats, or manipulation to get you to comply or stay silent *
Never
Very Frequently
Made you question reality? *
Never
Very Frequently
Have they taken your money, refused to give you money for essentials, or required you to account for every dollar spent? *
Never
Very Frequently
On a scale from 1 to 10, how much control do you feel you have over your own life right now? *
Complete control
No Control
Do you feel like you can safely express your opinions or disagree with this person? *
Check all that are true:
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms