Unhealthy Relationship Screening Tool |
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| Purpose: The Relationship Screening Tool is designed to assist students in assessing the health of their intimate relationships. This tool should only be used as a screening tool to instigate discussion; it is not a diagnostic tool. | ||||
| Rate how frequently your partner exhibits the following behaviors. Put an 'x' in the column that best describes your relationship. | ||||
| How often does your partner ... | Always |
Sometimes |
Rarely |
Never |
| 1. Embarrass you in front of others | __________ |
__________ |
__________ |
__________ |
| 2. Compliment you on something you did well | __________ |
__________ |
__________ |
__________ |
| 3. Blame you for making them upset or angry | __________ |
__________ |
__________ |
__________ |
| 4. Treat you roughly - grab, pinch, shove or hit you | __________ |
__________ |
__________ |
__________ |
| 5. Encourage you to spend time with friends and family | __________ |
__________ |
__________ |
__________ |
| 6. Check up on you to make sure you are where you said you would be | __________ |
__________ |
__________ |
__________ |
| 7. Make you feel as though you are incapable of making a decision | __________ |
__________ |
__________ |
__________ |
| 8. Pressure you to do things sexually that you do not want to do | __________ |
__________ |
__________ |
__________ |
| 9. Borrow or take money and not pay you back | __________ |
__________ |
__________ |
__________ |
| 10. Blame something you did or said for doing hurtful things to you | __________ |
__________ |
__________ |
__________ |
| 11. Support your academic and/or professional endeavors | __________ |
__________ |
__________ |
__________ |
| 12. Express displeasure with the way you look | __________ |
__________ |
__________ |
__________ |
| The following statements reflect how you feel about your partner's behavior. Mark if you strongly agree (SA), agree (A), disagree (D) or strongly disagree (SD) with how each statement applies to you in your relationship by putting an 'X' under the appropriate response for your relationship. | ||||
SA |
A |
D |
SD |
|
| 13. I try to do things that will not make my partner angry. | __________
|
__________
|
__________
|
__________
|
| 14. I am afraid of how my partner will react to things I do. | __________
|
__________
|
__________
|
__________
|
| 15. I feel safe in my relationship with my partner. | __________
|
__________
|
__________
|
__________
|
| 16. I feel the need to make excuses to others about my partner's behavior. | __________
|
__________
|
__________
|
__________
|
| 17. I trust that my partner will not go through my personal items. | __________
|
__________
|
__________
|
__________
|
| 18. I feel that no matter what I do my partner is not happy with me. | __________
|
__________
|
__________
|
__________
|
| 19. I wish that my partner would let me take time to do what I want to do. | __________
|
__________
|
__________
|
__________
|
| 20. When my partner gets angry it's because I have done something wrong. | __________
|
__________
|
__________
|
__________
|
| 21. I feel like an equal partner in my relationship. | __________
|
__________
|
__________
|
__________
|
| 22. I am afraid of what my partner would do if I ended the relationship. | __________
|
__________
|
__________
|
__________
|
| 23. I am comfortable telling others about what happens in my relationship. | __________
|
__________
|
__________
|
__________
|
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