1.How old are you?

2.Is your partner the jealous type?

Yes

No

3.Is your partner possessive?

Yes

No

4.Have you ever been abused?

Yes

No

5.Are you currently being abused?

Yes

No

6.Who is your abuser?

My boy friend

My husband

My significant other

A family member

7.How do you feel in their presence?

8.Why do you remain in that relationship?

9.Are you economically dependant?

Yes

No

10.Do you feel trapped?

Yes

No

11.Do you have a place to go?

Yes

No

12.Why don’t you confront him?

I feel afraid

He hits me

I don’t know how

13.Have you ever been sexually forced?

Yes

No

14.Are you receiving psychotherapy?

Yes

No

15.Would you like to receive treatment?

Yes

No

16.Does your partner choose your friends?

Yes

No

17.Do you feel manipulated?

Yes

No

or