Survey of Marital Abuse

 

Though this survey begins with one type of abuse and progresses through other types it is not to be construed that any type of abusive situation is denigrated. The survey simply begins with what the developer sees as the most common type of abuse and progresses to that which is least common, though not uncommon. If there is any question about what the survey means by any of its inquiries, the client should inquire of their counselor.

 Your name __________________________________________________________________________

 The name of your spouse is _____________________________________________________________

 By what name do you call him/her? _______________________________________________________

 How long in years and months have you been married? _____ years and _____ months total

Was abuse present in the relationship prior to your marriage?        Yes / No (circle one)

Did you cohabit together prior to your marriage?                           Yes / No (circle one)

Were you sexually active together prior to marriage?                     Yes / No (circle one)

 How many times have you been married? _____ If you more than once, was an abuse present in any of your previous marriages? Yes / No (circle one)

On the reverse side write in the names of previous spouses in the order you were married to them and indicate the amount of time you were married to each. Indicate by each if they were abusive or not.

 Have you ever been involved in other relationships during your life that was abusive?  Yes / No

If the answer is yes continue with this portion of the questionnaire.

Put a check by all the following statements that are true.

___ I have been involved with cohabitation relationships that were abusive.

___ I have been involved with dating relationships that were abusive.

___ My parents or one of my parentís friends were abusive.

___ I was abused as a child by a family member or a friend of the family.

       (If checked underline which or both)

On the reverse side use the indicated portion to describe any checked responses in this section. If you need additional paper your counselor will provide it.

 Verbal Abuse Verbal abuse is the most common form of abuse and it is present when almost every other type of abuse takes place. Verbal abuse involves the least controllable member of the body, the tongue.

Check the following statements that are true

___ My spouse verbally abuses me. (In cases of separation or divorce answer true as if present tense applies.)

___ My spouse verbally abuses me by raising their voice, shouting, or screaming.

___ My spouse uses cursing when he/she verbally abuses me.

___ My spouse uses demeaning language when he/she verbally abuses me.

         (Examples of demeaning language would be words that say a person is no good, fat, ugly, stupid, etc.)

___ My spouse uses verbal abuse if my actions do not please him/her.

___ My spouse uses threatening body language. (Threatening body language includes aggressive inclining the body

         toward the other person, use of hands in wild gesture, etc., attempting to maneuver so as to tower over the other person.)

___ My spouse verbally abuses me by bringing up my past.

___ My spouse verbally abuses me by criticizing my family.

___ My spouse verbally abuses me in front of children, friends, or family.

 I need to tell the counselor the following about my experience of verbal abuse:

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

Previous Marriages

 My first marriage was to ________________________________ we were married ___ years and ___ months.

This marriage ___ was, ___ was not abusive. If it was abusive, but not in the same way as your current marriage, indicate how it is different.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 My second marriage was to _____________________________ we were married ___ years and ___ months.

This marriage ___ was, ___ was not abusive. If it was abusive, but not in the same way as your current marriage, indicate how it is different.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 My third marriage was to ______________________________ we were married ___ years and ___ months.

This marriage ___ was ___ was not abusive. If it was abusive, but not in the same was as you current marriage, indicate how it is different.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

(If you have had more than three previous marriages, talk this over with your counselor.)

 Other Abusive Relationships

 How many cohabitation relationships have you been in that were abusive? ____

What was the longest period you were in an abusive relationship of this type?         ___ yrs. and ___ mos.

What was the shortest time you were in an abusive relationship of this type?        ___ yrs. and ___ mos.

If the abusive relationship(s) were unlike that in you current marriage, describe how they were different below:

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 How many dating relationships have you been in that were abusive? ___

What was the longest period of time you dated someone who abused you? ___ yrs. ___ mos. ___ times.

If the dating abuse(s) were unlike that in your current marriage, describe how they were different below:

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 If your parent(s) or family member was abusive tell who and how. _______________________________

 ___________________________________________________________________________________

 ___________________________________________________________________________________

 If your parentís friend(s) or your friend(s) were abusive tell who, which relationship, and how. __________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

Emotional Abuse Though verbal abuse is often emotional abuse as well; it also can incorporate with or be exclusively limited to mental abuse. Emotional abuse also takes place when physical and sexual abuse occurs. The inquiry here is limited to specific areas of emotional abuse where forms other than mental may or may not be present. Emotional abuse has to do with what you are feeling within yourself as a response to the activities of another person, which in this case is your spouse.

___ My spouse emotionally abuses me.

___ I have fears of being abandoned as a result of what my spouse is communicating to me.

___ I often feel dumb, ugly, clumsy, or somehow less worthwhile after being with my spouse.

       (Circle all that apply)

___ Sometimes sleep evades me because of something that has taken place in relationship with my

       Spouse.

___ My children either do not, or I feel they do not, respect me because of what my spouse conveys in

       his/her attitude towards me.

___ I do not think as highly of myself as I once did before I married.

___ Some things I once did, I am no longer confident to perform because of my spouseís opinion.

___ I have nightmares in which my spouse is a central negative figure.

___ I fear, though they have done nothing, my spouse might like to kill me or do me harm

 I need to tell the counselor the following about my experience of emotional or mental abuse.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 Physical Abuse Physical abuse might incorporate other forms of abuse into its makeup. But for our purposes inquiry is confined to actions that involve active contact, the threat and use of violence, and the withholding of the necessities for life and health.

___ My spouse physically abuses me. By denial of needs ___. Pushing & Shoving ___ Violence ___.

 If physical needs have been denied, whether it be food, clothing, medical care, prescriptions, etc. Describe that abuse below.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 Physical abuse performed by physical contact including violence is not in Godís plan for marriage partners any more than other forms of abuse. Sometimes people misidentify physical abuse that involves grabbing sexual organs, i.e. breasts and genitalia as sexual abuse when it is only aimed at inflicting pain and not intended to be sexual. Pinching, punching, scratching are abusive when they are more than occasional; inflict real pain; done with malice; prolonged; against the recipients will. Abuse is abuse whenever the recipient feels abused.

 Describe the physical contact or violence abuse you experience below.

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

 ____________________________________________________________________________________

SEXUAL ABUSE- Sexual abuse, like physical abuse can include not only what is done to a person, but in a marriage include what is denied the spouse in the marriage relationship. Sexual abuse is both passive and active, and does not necessarily involve physical contact. If you have a history of being sexually abused it should have already shown up in the first part of your responses to questions about abuse from others. If you omitted to respond to that inquiry during the first part of your survey preparation, please go back and do so, If you need more room write on the back of this and the preceding page.

 Many people find it difficult to respond to inquiries concerning sexual abuse. Sometimes they are not sure what they have experienced is sexual abuse. The design of this part of the inquiry is longer and more detailed than the preceding portions because of the survey. By the time you have checked the parts applicable to you, communication about the problem with your counselor should actually be a little easier.

 ___ I have been sexually abused by being denied the normal coital relationship within marriage by my

       spouse.

___ I have been sexually abused by being forcibly took sexually by my spouse.

___ I have been sexually abused by being forced to have sexual relationship with my spouse at improper

       or inconvenient times and/or places.

___ I have been sexually abused by my partner inflicting pain upon me in sexual activity.

___ I have been sexually abused by being forced to perform sexual acts that made be feel demeaned.

___ I have been sexually abused by having my sexual performance harshly mocked by my spouse.

___ I have been publicly ridiculed as a sexual partner.

___ I have been sexually abused by being forced to watch pornographic films, etceteras, by my spouse.

 ___ I have been sexually abused by being put on physical display before others by my spouse.

___ I have been sexually abused by being forced to have sexual contact in front of the children.

___ I have been sexually abused by being forced to be present when others were engaging in sexual

       activity.

___ I have been sexually abused by being forced to have sexual relationships with other people by my

       spouse.

___ I have been sexually abused by being coerced into participation in group sexual activity.

 ___ I have been sexually abused through being forced into sadistic sexual roles by my spouse.

___ I have been sexually abused through being forced into masochistic sexual roles by my spouse.

___ I have been sexually abused through being forced into bondage sexual roles by my spouse.

___ I have been sexually abused by being forced into lesbian/homosexual encounters by my spouse.

___ I have been sexually abused by being forced into participation in bestiality by my spouse.

 ___ I have been sexually abused by my spouse in ways not covered in this survey

 What I would like to tell my counselor about my experience of sexual abuse is _____________________

 ___________________________________________________________________________________

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            Jonsquill Ministries

P. O. Box 752

Buchanan, Georgia 30113

171001-1