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.