Domestic violence

How old are you?

What is your gender?

Male

Female

Other

Describe your views on the issue of domestic violence

From 1- 7 (1 being the best and 7 being the worst), how would you rate your experience of living at home?

Between the ages of 5- 15, how often would forms of discipline involve physical force?

Never

Sometimes

Often

Most of the time

Have you ever needed to access any counselling services due to an occurrence of family violence?

Yes

No

From ages 5-15, what was the likelihood of you witnessing a violent act occur within your household?

Low

Average

High

In situations of conflict, how often do you resort to acts of aggression (including verbal and physical)?

Never

Sometimes

Most of the time

How often do you experience forms of verbal, psychological and phsyical violence within an intimate relationship?

Never

Rarely

Often

From 1-7 (1 being the most and 7 being the least), what would you rate the influence your up bringing has had on your intimate relationships?