Violence History Form

Physical Violence

• Slapped
• Grabbed
• Punched
• Pushed
• Kicked
• Kneed
• Choked
  
• Pushed to ground
  
• Bit
  
• Sit on or stood on
  
• Burned
  
• Spit on
  
• Drowned
  
• Hair pulled
  
• Arm twisted
  
• Head/body banged against wall
  
• Pinned to the ground or up against the wall
  
• Thrown out of car, out window, etc.
  
• Pushed down steps or onto ground
  
• Hung by neck, arms/ feet
  
• Handcuffed Tied up with rope
  
• Clawed or scratched
  
• Forced to eat non-edible/poisonous substances
  
• Threatened with knife
  
• Threatened with gun
  
• Threatened with other object
  
• Knife used
  
• Gun used
  
• Hit with object

Sexual Violence

• Forced/coerced partner to engage in vaginal intercourse
• Inserted objects into partner against her wishes
• Fondled genitals/buttocks/breasts against her wishes
• Exposed self in front of partner against her wishes
• Forced/coerced partner to expose herself
  
• Masturbated partner against her wishes
  
• Masturbated self in front of partner against her wishes
  
• Forced/coerced partner to engage in anal intercourse
  
• Forced/coerced partner to engage in oral sex
  
• Forced/coerced partner to masturbate you
  
• Partner beaten on genitals
  
• Partner's genitals mutilated
  

Psychological Violence:

• Isolation of partner
  
• Induced debility producing exhaustion
  
• Pathological jealousy and obsessivenss
  
• Threats
  
• Degradation
  
• Forcing your partner to use alcohol or drugs.
  
• Invalidating your partner's perceptions
  
• Occassional indulgences