RELATIONSHIP LETHALITY CHECKLlST

This questionnaire is designed to help to help you decide if you are living in an abusive situation. There are different forms of abuse, and not every person experiences all of them. Below are various questions about your relationship. As you can see, each possible answer has points assigned to it. By answering each question, and then totaling these points as directed, you can compare your score with the abuse index. You will know if you are living in a potentially violent situation; and if abuse is occurring, you will have an estimate of how lethal the abuse is.

Step 1 of 2

Frequently-3 Sometimes-2 Rarely-1 Never-0
Directions: Please number your response to each question according to the chart below. Be honest, this checklist is for you.
1. Does your partner continually monitor your time and make you account for every minute (when you run errands, visit with friends, commute to work, etc.)?
Please enter a number less than or equal to 3.
2. Does your partner ever accuse you of having affairs?
Please enter a number less than or equal to 3.
3. Is your partner ever rude to your friends?
Please enter a number less than or equal to 3.
4. Does your partner ever- discourage you from starting friendships P
Please enter a number less than or equal to 3.
5. Do you ever feel isolated and alone, as if there is no one close to you to confide in?
Please enter a number less than or equal to 3.
6. Is your partner overly critical of daily tliings, such as your cooking, your clotl1es, your housework, or your appearance?
Please enter a number less than or equal to 3.
7. Does your partner demand a strict amount of how you spend money?
Please enter a number less than or equal to 3.
8. Do you quarrel much over financial matters?
Please enter a number less than or equal to 3.
9. Does your partner's mood change radically, from very calm to very angry, or vice versa?
Please enter a number less than or equal to 3.
10. Is your partner disturbed by you working or by the thought of you working or attending school?
Please enter a number less than or equal to 3.
11. Does your partner become angry more easily if he/she drinks or uses drugs?
Please enter a number less than or equal to 3.
12. Does your partner pressure you for sex more often than you are comfortable with or when you are ill?
Please enter a number less than or equal to 3.
13. Does your partner become angry if you don't want to go along with his requests for sex?
Please enter a number less than or equal to 3.
14. Do you argue about having children or how to raise them?
Please enter a number less than or equal to 3.
Frequently-6 Sometimes-5 Rarely-4 Never-0
Number the response to each question that best describes your relationship.
15. Has your partner ever struck you with his/her hands or feet (slap, punch, kick, etc.)?
Please enter a number less than or equal to 6.
16. Has your partner ever threatened you with an object or weapon?
Please enter a number less than or equal to 6.
17. Has your partner ever struck you with an object?
Please enter a number less than or equal to 6.
18. Has your partner ever threatened to kill you, your kids, or himself/herself?
Please enter a number less than or equal to 6.
19. Has your partner ever given you visible injuries (such as welts, bruises, cuts, lumps, etc.)?
Please enter a number less than or equal to 6.
20. Has your partner ever caused you injuries because of violence at home?
Please enter a number less than or equal to 6.
21. Have you ever had to seek professional aid for injury at a medical clinic, doctor's office, or emergency room?
Please enter a number less than or equal to 6.
22. Has your partner ever hurt you sexually by forcing you to have intercourse or perform acts against your will?
Please enter a number less than or equal to 6.
23. Is your partner ever violent toward children?
Please enter a number less than or equal to 6.
24. Is your partner ever violent toward people outside your family and home?
Please enter a number less than or equal to 6.
25. Does your partner ever throw objects or break things when angry?
Please enter a number less than or equal to 6.
26. Has your partner ever been in trouble with the police?
Please enter a number less than or equal to 6.
27. Have you ever called the police, or tried to call them, because you felt you or other members of your family were in danger?
Please enter a number less than or equal to 6.
28. Has someone outside your home ever called the police regarding your family's safety?
Please enter a number less than or equal to 6.
29. Has your partner ever humiliated you in public, or in front of friends and family?
Please enter a number less than or equal to 6.
30. Does your partner make you feel as if you are crazy?
Please enter a number less than or equal to 6.
31. Does your partner make you feel dirty or that there is something wrong with you?
Please enter a number less than or equal to 6.
32. Do you need your partner's approval to make decisions?
Please enter a number less than or equal to 6.
33. Do you lie to protect your relationship?
Please enter a number less than or equal to 6.
34. Does your partner make you feel unimportant?
Please enter a number less than or equal to 6.
35. Does your partner's presence intimidate you?
Please enter a number less than or equal to 6.
36. Does your partner belittle you for initiating sex?
Please enter a number less than or equal to 6.

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RELATIONSHIP LETHALITY CHECKLlST

Step 1 of 2

Frequently-3 Sometimes-2 Rarely-1 Never-0

Frequently-6 Sometimes-5 Rarely-4 Never-0

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24-Hour Crisis Hotline: (800) 956-6656 • All Services Are Free & Confidential

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