Intimate Partner Violence Screening Tool
Name
Date
1. Have you ever felt afraid of your partner or ex-partner?
Yes
No
2. Has your partner or ex-partner ever physically hurt you?
Yes
No
3. Has your partner or ex-partner ever insulted, belittled, or threatened you?
Yes
No
4. Has your partner or ex-partner ever forced you to do something sexual you did not want to do?
Yes
No
5. Is there anything else you would like to share?
Screened By