This page can be printed out, or write down your responses to each behavioral description on a sheet of paper.

Write the number which best describes your experience.
Never - 1    Once or Twice - 2    Sometimes - 3    A lot -  4

Behaviors of a Partner/Former Partner
__ 1.  Discusses issues calmly.
___2.  Sulks, refuses to talk.
___3.  Stomps out in order to punish.
___4.  Screamed, insulted, swore at you, or called you names
___5.  Withdraws affection in order to punish.
___6.  Verbally pressured you to have sex.
___7.  Threatened to leave the relationship (to have an affair).
___8.  Threatened punishment other than physical (taking away     children).
___9.  Restricted physical movement or social contact.
___10. Intentionally interrupted your sleeping or eating.
___11. Destroys your property.
___12. Kicked, maimed, or killed your pet(s)
___13. Withholds money.

Direct Threats of Violence
___1.  Threatened to hit or throw something at you
___2.  Directed anger at or threatened the children
___3.  Directed anger at or threatened the pets
___4.  Threatened to kill you or self

Direct Violence

___1.  Throw, hit or kick something
___2.  Throw something at you
___3.  Pushed, shoved, or grabbed you
___4.  Threw or carried you (on the bed)
___5.  Slapped or spanked you
___6.  Restrained or held you down
___7.  Wrestled in fun that ended up in hurting you
___8.  Bit or scratched you
___9.  Pulled your hair
___10. Spit at you
___11. Drove recklessly to frighten you
___12. Choked or strangled you
___13. Physically forced sex on you
___14. Punched or kicked you
___15. Burned you (cigarette burn)
___16. Kicked or punched you in stomach when pregnant
___17. Beat you unconscious
___18. Threatened you with knife, gun, or other weapon
___19. Used any weapon against you (bat, common household items, other items)

Who do I talk to? Call Anna Marie’s shelter to speak with a women’s advocate anytime. Women’s advocates are here to help you 24 hours each day, seven days a week (320) 253-6900, or call the Minnesota Toll Free Domestic Violence Crisis Line   1-866-223-1111. You will automatically be connected with the battered women’s shelter closest to you.