SOUTHEAST TENNESSEE LEGAL SERVICES
|
SOUTHEAST TENNESSEE LEGAL SERVICES
|
|
|
We use this questionnaire
for determining whether we can represent you, in helping you to obtain an Order
of Protection, in finding out what social services you may need, and in
formulating what we will ask you and your abuser during depositions and at trial
in your divorce case. For the full questionnaire in
Microsoft Word
click
here
or in
Adobe Acrobat click
here.
If you do
not have a copy of
Adobe
Acrobat Reader,
please click below to get a copy.
You can use the questionnaire to come to terms with a spouse's or partner’s behavior that you may have been unwilling to address.
Pushed you? ____ yes _____ no
How often did it happen? _____ frequently ______ occasionally _______ rarely Where did it happen? ______ in public ______ in private Did anyone else witness the incident? _____ yes ______ no If yes, who? ______________________________________ Did anyone see injuries resulting from the incident? ______ yes ______ no Did anyone else know about the incident? ______ yes ______ no If yes, who? _______________________________________ Last date of occurrence _________________
[Similar details are needed for each of the following questions too.]
Grabbed you? Held you down? Thrown you? Slapped you? Hit you with his fist? Kicked you? Choked you? Put his hand over your mouth? Thrown an object at you? Used a weapon against you? Locked you in? Damaged your property? Hurt an animal? Driven recklessly while you were in the car? Kept your keys? Discouraged you from leaving the home? Discouraged you from having a job or going to school? Refused to let you have a checking account? Discouraged you from attending your preferred church? Discouraged you from visiting family? Discouraged you from visiting friends? Discouraged you from doing a favored activity? Threatened to hurt you with violence? Threatened to take away or damage your property? Threatened to take custody of the children? Threatened to harm himself if you left him? Threatened to say something harmful about you to others? Refused to let you get medical attention or treatment when you needed it? Withheld physical affection from you? Forced you to have sex? Caused you to have injuries during sex? Been rough during sex? Criticized your physical appearance? Suggested no one would want you? Called you demeaning names? Criticized the way you dressed? Criticized you as a mother? Criticized you as a wife? Criticized your education or your job ability? Criticized your family? Criticized your friends? Accused you of having affairs or wanting affairs? Blamed you for problems? Called you names? Made fun of your beliefs or ideas?? Made your family or friends uncomfortable? Made negative comments about you in front of the children? Made negative comments about you in front of friends, family or in public? Suggested that something you thought happened really didn’t happen? Humiliated you? Accused you of things you did not do? Threatened to leave you? Checked up on you a lot? Called you obsessively? Followed you to places? Called you or contacted you at times that were inconvenient to you? Accused others of wanting to have affairs with you? Denied doing things he has done that hurt you? Moved you away from friends or family? Suggested you were crazy? Hurt the children in any way? Withheld affection from the children? Ridiculed the children?
_____ Jealous _____ Controlling _____ Possessive _____ Bad temper _____ Moody _____ Financially irresponsible _____ Alcohol problems _____ Drug problems _____ Pornography _____ Affairs _____ Compulsive spending _____ Gambling _____ Illegal income _____ Criminal record _____ Workaholic _____ Religious _____ Unstable work history _____ Violence toward others _____ Violence in family
_____ Didn’t know her _____ Friendly _____ Open _____ Passive _____ Neglectful _____ Emotionally distant _____ Critical of you _____ Critical of your spouse or partner _____ Controlling _____ Over-involved _____ Religious _____ Abusive towards the father _____ Abusive toward your spouse or partner _____ Affairs _____ Abandoned or left home early _____ Divorced
_____ Didn’t know him _____ Passive _____ Neglectful _____ Emotionally distant _____ Controlling _____ Over-involved _____ Religious _____ Abusive toward the mother _____ Abusive toward your spouse or partner _____ Affairs _____ Abandoned or left home early _____ Divorced
This website was supported by Grant Nos. 2001-WL-BX-0023 and 02-DB-BX-0047 awarded by the Violence Against Women Grants Office, Office of Justice Programs, U.S. Department of Justice and a sub-grant from the Office of Criminal Justice Programs, State of Tennessee. Points of view in this website are those of the author and do not necessarily represent the official position or policies of either government.
|
|
|
