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Domestic violence affects individuals, children, families in every community regardless of marital status, age, gender, race, income, ethnicity, religion, physical ability or sexual orientation. If you are in an abusive relationship or domestic violence situation know that you are not alone and there is support available.

ARE YOU IN A RELATIONSHIP WITH AN ABUSER?

The Cycle of Abuse

Recognizing the Forms or Signs of Abuse

Do or have you experienced any of the following forms of abuse? *

Pushing, hitting, slapping, choking, kicking, biting Threatens you, your children, or to harm family members or pets Threatens to commit suicide or to kill you/child(ren) Threatens to take your child(ren) Keeps you from your family or friends Takes or keeps your money Sabotages your livelihood, tries to or keeps you from working Uses or threatens to use a weapon Forces you to have sex or perform sexual acts against your will Tries to make you feel guilty about things you are not responsible for Constantly puts you down; becomes verbally abusive

Does your partner *

Destroys property (home, furniture) or things you care about like family pictures, clothing Accuses you of having affairs Apologizes, give gifts or makes promises to change or that it won't happen again Drinks or use drugs Take your keys or prevents you from leaving the home Blames you for the behavior displayed towards you Criticizes or puts you down Sees and treats you as an object or property instead of a person Screams and yells at or humiliates you Publicly insults, ridicules or humiliates you

If Other please specify: *

Do you ever feel as though you are *

Walking on eggshells At fault and can never do anything right Alone and no will understand Mistreated, abused or hurt because you deserve it Helpless or emotionally numb Afraid of your partner most of the time Crazy or losing your mind

Controlling or violent behavior or threats displayed by your partner *

Constantly checking on you and your whereabouts Keeps you from seeing your family or friends Threatens to commit suicide or kill you if you leave Forces you to have sex or perform sexual acts against your will Restricts your access to money, accounts, car or phone usage Destroys your personal belongings Has a unpredictable temper

* Indicates required field

What is your age? *

13-18 19-25 26-35 36-50 Over 50 Prefer not to say

Comment *

Name *

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Last

Phone Number *

Email *

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