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Questionnaire

Please fill in the questionnaire and then hit the Submit button at the bottom of the page.

Please note that for the safety of any victims of abuse, no reply or confirmation of receipt of the questionnaire will be forwarded to you. If you have any specific queries or would like an answer, please send me an email directly.

Any details given in this form are for the sole use of Hidden Hurt and will not be available to any other parties.

Thank you for taking the time to fill in the questionnaire!

About you

Are you male female

Age range

Where do you live?

if other, please specify

Are you
abuser
other, please specify

If you are a victim or survivor of abuse

What types of abuse have you/do you suffer? (please tick all which apply)

Physical abuse Verbal abuse
Sexual abuse Financial abuse
Emotional/psychological abuse Spiritual abuse

If you have suffered any other form of abuse, please specify

Specific questions on types of abuse experienced:

If you have suffered Physical Abuse please tick the options that apply:

What sorts of physical assault have you experienced?

pushing or shoving causing NO injury

pushing or shoving causing injury (eg bruising)

hitting, slapping or punching causing NO injury

hitting, slapping or puching causing injury

kicking

pulling your hair

attempted strangulation

using an object to harm or hit you, please specify what

burning you (eg stubbing out cigarette on you, using hot water to scald you, trying to set light to you

hitting your head or body against wall

What part of your body was targeted during the physical assault(s)?

head
torso
arms and hands
legs and feet
genitalia (eg breast and crotch area for women, crotch area for men)

What sort of injuries have you sustained due to physical assault(s)?

no injuries sustained
bruising or scratching NOT requiring medical intervention
bruising or scratching requiring medical intervention
cuts or gashes NOT requiring medical intervention
cuts or gashes requiring medical intervention
broken bone(s), if so, please state which
burns or scalds
injuries to genital areas, please give details
other injuries, please give details

About the frequency of assaults:

How soon after starting the relationship did the first physical assault take place?

How many times (approx.) have you been physically assaulted?

How many times (approx) were you assaulted BEFORE telling someone?

Have the physical assaults increased, stayed the same or decreased during your relationship?

Did the physical abuse start:

Have you ever tried defending yourself from a physical assault?

If you have suffered Sexual Abuse please tick the options that apply:

What sorts of sexual abuse have you experienced?

rape (vaginal) forced to watch/use pornography
anal rape (buggery) having sexually explicit photos taken of you
rape using an object excessive sexual jealousy (accusing you of infidelity)
forced prostitution calling you sexually derogarory names
forced sexual act excluding penetration criticising you sexually
forcing sex after physical assault withholding sex or
forced sex when you are ill or tired or incapacitated making sex conditional (on your behaviour, on taking part in sexual acts you don't want to, etc)

Any other forms of sexual abuse you have experienced?

If you have been raped, did your abuser use:

coercion (eg threats, accusing you of infidelity, not allowing you to sleep, saying to don't love him/her, etc)

only enough force to hold you in place but not enough to physically injure you

violence, ie force causing you injury

a weapon (eg a knife, etc)

About the frequency of sexual abuse:

How soon after starting the relationship did the first sexual abuse take place?

How many times (approx.) have you been sexually abused?

How many times (approx) were you sexually abused BEFORE telling someone?

Has the sexual abuse increased, stayed the same or decreased during your relationship?

If you have been raped, did you recognise it as rape at the time of the incident?

Have you sustained any injuries/diseases/pregnancy etc as a result of the sexual abuse?

sustained physical injury in genital area (bruising, tearing, etc)

sustained physical injury to breasts

sustained physical injury to other part of body

caught sexually transmitted disease

infection (skin, urinary tract, etc)

got pregnant

other, please give details

Domestic Abuse and Children

Do/did you have any children while with the abuser?

Is the abuser the other biological parent of the child/children?

How many children did you have while in the abusive relationship?

Did the children witness (heard or saw) any abuse on you from your partner?

If so, what sort of abuse? (please give details, eg physical assault, shouting, sexual assault, etc)

Where the children abused by your partner?

If so, what sort of abuse did your children suffer? (space for comments)

verbal abuse
emotional abuse
physical abuse NOT requiring medical treatment
physical abuse requiring medical treatment
sexual abuse

Have you ever been injured as a result of trying to protect your children?

If you are seperated from your abusive partner, do your children still have contact with him/her?

General Questions for ALL abuse types

What is/was your relationship to the abuser at the time of the abuse?

if family member or other, please specify

Is your abuser male or female?

Are you still living with or in close contact with your abuser?

yes no sometimes

How long have you been/were you in an abusive relationship?

How long had/have you been in an abusive relationship before confiding in someone?

About Support available

If you are still in an abusive relationship, have you confided in anyone?

yes no

if yes, whom have you told about the abuse?

Both current victims and survivors:

Of the following, how would you rate the help and support you have received?

 
Excellent
Good
Bad
Not sure
No contact
Family
Friend
DV Organisation
Police
Church Leader
Social Services

How long had the abuse been ongoing before you contacted an official body (eg Police, Refuge, Social Services)?

About Hidden Hurt

How did you come across Hidden Hurt?

How do you rate the information on Hidden Hurt?

Are there any topics which you feel have not been adequately covered in Hidden Hurt, or any other issues you would like to see on Hidden Hurt?

If you are happy for us to quote some of your experiences on Hidden Hurt, please tick this box.

Any other comments?

Please remember:
We cannot answer any questions included in this form.
If you wish to contact someone, please send an email (see Contact Page)

Thank you for taking the time to fill in the questionnaire. Your feedback is appreciated!

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Bridge Interactive Group
This information is provided for guidance only and you are strongly recommended to seek suitable expert advice and help.