Self-Reflection questionnaire

We invite you to consider the following questions, which may help you reflect on whether you—or someone you know—might be experiencing a situation of violence.

1. Have you ever felt, or do you currently feel, emotionally or psychologically harmed by your partner, a family member, or another person?

For example, constant insults, humiliation in private or public, destruction of valued objects, ridicule, manipulation, threats, or isolation from friends or family members.

YES

NO

2. Has your partner or another person recently hurt you or threatened to do so?

YES

NO

3. Has anyone ever touched you inappropriately or forced you to do something with your body or someone else’s body?

For example: touching, kissing, watching you while bathing, filming, sending or showing inappropriate photos or messages, exposing intimate parts.

YES

NO

4. Do you ever feel afraid or worried that your partner or someone else might hurt you physically?

YES

NO