Here is a list of behaviors that many women report have been used by their partners or former partners. We would like you to estimate how often these behaviors occurred during the 6 months before you began this program. Select from the list below for each item to show your closest estimate of how often the behavior happened in your relationship with your partner or former partner during the 6 months before you began the program.

Partner's Name:

Number of Physical Score:

Number of Psychological Score:

Questions: 7, 14, 18, 24-28. (9+ = total divided by 9) (All other questions: 20+ = total divided by 20)

Client Signature:

Today's Date: required

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