Santa Fe Psychotherapy & Consulting, LLC
505 424 3119 1925 Aspen Drive Suite 700 B, Santa Fe, N.M. 87505
Symptoms and Signs of Battering(1)
Name: Date:
Read each item carefully, then circle T(true) or F(false) on the line next to the item.
Physical abuse
Does or did your partner......
1. T F Hit, slap, punch, shove, bite, cut, choke, kick, burn or spit on you?
2. T F Throw objects at or restrains you?
3. T F Threaten to hurt you with an object or deadly weapon? (gun, knife, baseball bat, brick, chain, hammer, scissors, rope, belt buckle, extension cord, branch, bottle, acid, bleach, or scalding water.)
4. T F Abandon you or lock you out of the house/car?
5. T F Neglect you when you are sick or pregnant?
6. T F Endanger you or your children through reckless driving?
7. T F Threaten to or attempt to drown you?
Emotional abuse
1. T F Does your partner consistently say or do things that shame, embarrass, ridicule or insult you? Have you heard......
2. T F You are stupid, filthy, lazy, nasty, etc.?
3. T F You can't do anything right?
4. T F You are an unfit parent?
5. T F You don't deserve anything?
6. T F You'll never be able to get a job?
7. T F Who would want you? Does or did your partner...
8. T F Withhold affection to punish you?
9. T F Threaten to hurt you or your children?
10. T F Forbid you to work, handle your own money, make decisions, or socialize with your friends?
11. T F Refuse to provide sexually, emotionally or economically for you?
12. T F Force you to sign over property or give him your personal possessions?
13. T F Tell you about his affairs?
14. T F Accuse you of having affairs?
15. T F Undermine your sense of power and confidence?
16. T F Manipulate you with lies, contradictions or promises?
Sexual abuse
Does or did your partner.....
1. T F Force you to have sex when you don't want to?
2. T F Force you to perform sexual acts you don't want to?
3. T F Criticize your sexual performance?
4. T F Deny you sex?
5. T F Threaten to hurt you if you don't have sex with him/her?
6. T F Force you to have sex with, to watch or to be watched by others?
7. T F Commit sexual acts that you consider sadistic?
Destructive acts
Does or did your partner....
1. T F Break furniture, flood rooms, ransack or dump garbage in your house?
2. T F Slash tires, break windows, steal, tamper with parts or put foreign substances in the gas tank of your car?
3. T F Kill pets to punish or frighten you?
4. T F Destroy clothing, jewelry, or your personal belongings?
Economic abuse
Does or did your partner...
1. T F Withhold or control your money?
2. T F Refuse you use of family credit cards?
Paolo Giudici,Lpcc, Ladac Independent Psychotherapy Practice
PO Box 1491 Santa Fe NM 87504 505 466 1764
Symptoms and Signs of Battering
For clinical use only. Not to be filled by client.
ABUSED
PHYSICAL
□ Obvious physical injuries such as cuts, bruises, burns, black eyes, swollen lips, bumps on head, etc.
□ Not visible injuries such as on breasts, stomach, portions of head covered with hair, testicles, sexual abuse, internal injuries, cracked ribs, hair pulled out, etc.
BEHAVIOR
□ Victim will not speak up to defend her/himself or tell her/his side of the story.
□ Victim expresses fear of being with spouse or fear of leaving him/her
□ Victim talks solely about spouse; explanation and excuse for spouse's behavior.
□ Victim reports that s/he has no friends or relatives to turn to.
□ Victim expresses feeling of craziness, helplessness.
ABUSER
PHYSICAL
□ Scratches on face, arms hands, etc. (Victim may have tried to defend her/himself.
BEHAVIOR
□ Expresses excessive jealousy of spouse, spouse not permitted to go out.
□ Expresses need to control spouse.
□ Speaks of spouse in demeaning terms.
□ Minimizes violent behavior. ("I just shook her", "I just slapped her", "I only want to keep her in line", etc.
□ Makes threats.
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