Domestic Violence Screening
After filling the details click on the SUBMIT button.
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indicates required fields
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Are you afraid to say what you think?:
Yes
No
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Afraid to do the things you like to do?:
Yes
No
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Hurry to respond to call/text for fear of a fight?:
Yes
No
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Does he ignore or reject you as “punishment” ?:
Yes
No
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Agree to the things he says to avoid arguements?:
Yes
No
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Have to report where you are at all times?:
Yes
No
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Does he refuse to apologize or admit you’re right?:
Yes
No
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Does he insist that everything is your fault?:
Yes
No
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Does he start a fight so he can go out?:
Yes
No
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Does he spend money designated for bills?:
Yes
No
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Does he accuse you falsely of infidelity?:
Yes
No
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Does he publicly shame or embarrass you?:
Yes
No
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Does he control your friendships?:
Yes
No
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Does he slam/hit/throw things to show his anger?:
Yes
No
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Does he threaten to take/hurt your children?:
Yes
No
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Does he call often daily to see where you are?:
Yes
No
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How would you like us to contact you?:
E-mail
By Phone
By Postal Mail
Any of the above
Do not contact me - Pray
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Name:
Home Address:
Phone:
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E-mail Address:
*
Best time to contact you:
After filling the details click on the SUBMIT button.
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After filling the details click on the SUBMIT button.
