Checklist for Victims

SOUTHEAST TENNESSEE LEGAL SERVICES

 

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Marion County Courthouse, Jasper

 

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. For the full questionnaire click here.   If you do not have a copy of Adobe Acrobat Reader, please click below to get a copy.
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Has your spouse or partner done any of the following things to you? 

 

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

       didnít 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? 

                       

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Describe any traits that fit your spouse or spouse or partner:

 

  _____ 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

 

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Describe any traits that fit your spouse or partnerís mother:

 

_____ Didnít 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

 

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Describe any traits that fit your spouse or partnerís father:

 

_____  Didnít 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

 

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Give your history of the relationship in brief:

This website has been supported by grants 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.

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