Questionaire (2 copies, to be filled out by safe guard and offender separately)

Abuse takes on many forms, some more apparent than others. Often abuse is intergenerational and it's forms passed down from grandparents, to parents and eventually continued generation by generation without thought or question. On the following questionaire please check all items where this has occurred at least once. If you have seen your parents use any of these forms place a "P" next to the item; if you have on any occasion used one of the following forms place a "S" column in the column.

Violence:

Committed incest

Used sexual touching/kissing

Sexualized children's behavior

Used pinching

Used hitting

Used kicking

Used twisting arms

Used choking

Intimidation:

Instilled fear through looks, actions, gestures, property destruction

Used your adult size

Yelling

Being violent to other parent, pets, etc.

Using Institution:

Threatened punishment with/by God, courts, police, school, juvenile detention,

Foster homes, relatives, psych wards

Isolation:

Controlled access to peers/adults, siblings, other parent, grandparents

Emotional Abuse:

Put downs, name calling

Using children as confidants

Using children to get or give information to other parent

Being inconsistent

Shaming children

Economic Abuse:

Withholding basic needs, using money to control behavior

Squandering family money

Withholding child support

Using children as an economic bargaining chip in divorce

Threats:

Threatening abandonment, suicide, physical harm, confinement or harm to other loved ones

Using Adult Privilege:

Treating children as servants

Punishing, bossing, always winning

Denying input in visitation and custody decisions

Interrupting

Incentives:

Favors

Privileges

Personal time and attention

Provided transportation

Provided money

Provided promise of gifts/events

Signature: __________________________Date: ______________