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  2. 2013
  3. November
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  5. Violent Parents, Violent Children?
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What is your gender?
 
Male
 
Female
 
 
 
Who do you live with?
 
Mother
 
Father
 
Both
 
Other
 
 
 
Have you ever been spanked?
 
Yes
 
No
 
 
 
If so, at what age did it stop?
 
1-3
 
4-7
 
8-11
 
12-14
 
Other
 
 
 
Have you ever witnessed your mother or father being physically violent towards each other?
 
Hit
 
Push
 
Scratch
 
Punch
 
Kick
 
None
 
 
 
When you get angry do you …

 
Yell
 
Cry
 
Punch walls
 
Physically abuse another
 
 
Please answer truthfully to the following questions.
Yes No
Have you ever been in trouble with the law?
Have you ever skipped school?
Have you ever stolen anything?
Have you ever experimented with drugs and alcohol?
 
 
 
Have you or your parent/guardian been diagnosed with a mental disorder?
 
Me
 
Mother
 
Father
 
Guardian
 
None
 
 
 
Have you ever been in an abusive relationship?
 
Yes
 
No
 
 
 
What is/was your relationship like with your parents?
 
Inadequate parental guidance and supervision
 
Equal parent-child relationship
 
You are/were forced to take on the role of the parent
 
None of the above