Behaviour Checklist

Print PDF

 

Never

Once

Frequently

  1.  ISOLATION

Restricting freedoms:

 

 

 

a.  Told you that you cannot do something.

 

 

 

b.  Monitored your time and made you account for where you were.

 

 

 

c.  Did not allow you to leave the house.

 

 

 

d.  Made it difficult for you to get a job.

 

 

 

e.  Restricted your use of the vehicle.

 

 

 

f.  Restricted your use of the telephone.

 

 

 

g.  Tried to prevent you from contacting your family and friends

 

 

 

h.  Kept you from getting medical care.

 

 

 

i.  Others (Please explain)

 

 

 

2.  MALE PRIVILEGE

 

 

 

a.  Demanded obedience.

b.  Made decisions without your input.

c.  Treated you like an inferior.

d.  Told you that you couldn’t cope without him.

e.  Talked about women as if they are inferior.

f.  Treated you like a servant.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

g.  Others (Please explain)

 

 

 

3.  ECONOMIC ABUSE

 

 

 

a.  Made you account for all the money you spent.

b.  Kept you short of money.

c.  Made you ask for basic necessities.

 

 

 

 

 

 

 

 

 

3.  ECONOMIC ABUSE  (CONTINUED)

Once

Twice

Three Times

d.  Support payments for you and/or your children withheld or late.

 

 

 

e.  Sold your possessions or co-owned property without your knowledge.

 

 

 

f.  Built up debts, which you are jointly liable for.

 

 

 

g.  Cleaned out your joint bank account.

 

 

 

h.  Restricted you to an allowance.

 

 

 

i.  Others (Please explain)

 

 

 

4.  INTIMIDATION

 

 

 

a.  Changed his mood suddenly.

 

 

 

b.  Gave you the silent treatment.

 

 

 

c.  Showed you that he/she was getting angry.

 

 

 

d.  Shouted or yelled.

 

 

 

e.  Pounded a fist on the table.

 

 

 

f.  Hit the wall.

 

 

 

g.  Threw or kicked something.

 

 

 

h.  Stomped out of the room/house.

 

 

 

i.  Killed or neglected the animals.

 

 

 

j.  Frightened you into submission.  (i.e. to get own way)

 

 

 

k.  Others (Please explain)

 

 

 

5.  EMOTIONAL ABUSE

 

 

 

a.  Said things designed to spite or insult you in front of others.

 

 

 

b.  Put down your physical appearance.

 

 

 

c.  Made out that you were stupid.

 

 

 

d.  Criticized your care of children/home.

 

 

 

e.  Criticized your family and/or friends.

 

 

 

f.  Called you names and swore at you.

 

 

 

g.  Told you that you were crazy/irrational.

 

 

 

h.  Undermined you (i.e. parenting, attempts to improve yourself)

 

 

 

i.  Changed his plans to visit children, or cancelled arranged custody visits.

 

 

 

5.  EMOTIONAL ABUSE (CONTINUED)

 

 

 

J.  Blamed you for his/her problems.

 

 

 

k.  Others (Please explain)

 

 

 

6.  SEXUAL ABUSE

 

 

 

a.  Withdrew affection.

 

 

 

b.  Was excessively jealous.

 

 

 

c.  Made birth control solely your responsibility.

 

 

 

d.  Did not allow you to use birth control.

 

 

 

e.  Nonconsensual use of objects (sexually).

 

 

 

f.  Flaunted affairs.

 

 

 

g.  Made sexual accusations that you were having affairs.

 

 

 

h.  Withheld sex to punish you.

 

 

 

i.  Pressured you to have sex when you were saying no.

 

 

 

j.  Forced you to have sex against your will.

 

 

 

k.  Pressured you to have sex after being abusive towards you.

 

 

 

l.  Pressured or forced you into unwanted sex acts.

 

 

 

m.  Treated you like a sex object.

 

 

 

n.  Purposely inflicted pain on you during sex.

 

 

 

o.  Sex accompanied by violence and/or threats.

 

 

 

p.  Sexual name calling.

 

 

 

q.  Nonconsensual use of pornography.

 

 

 

r.  Others (Please explain)

 

 

 

7.  PHYSICAL ABUSE

 

 

 

a.  Threw you.

 

 

 

b.  Pinched you.

 

 

 

c.  Bit you.

 

 

 

d.  Tripped you.

 

 

 

e.  Pushed you.

 

 

 

f.  Grabbed you.

 

 

 

g.  Shook you.

 

 

 

7.  PHYSICAL ABUSE  (CONTINUED)

 

 

 

h.  Pulled your hair.

 

 

 

i.  Twisted your arm.

 

 

 

j.  Pinned you to the wall, floor or bed.

 

 

 

k.  Choked or strangled you.

 

 

 

l.  Kicked you.

 

 

 

m.  Slapped you.

 

 

 

n.  Punched you.

 

 

 

o.  Scratched you.

 

 

 

p.  Covered your mouth.

 

 

 

q.  Restrained you.

 

 

 

r.  Smothered you.

 

 

 

s.  Forcefully put you out of the house.

 

 

 

t.  Hit or tried to hit you with something.

 

 

 

u.  Threatened you with a knife, gun or other weapon.

 

 

 

v.  Tried to run you down with a vehicle.

 

 

 

w.  Assaulted you when you were pregnant.

 

 

 

x.  Others (Please explain)