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  Have you ever been directly involved in domestic violence?
 
Yes
 
No

 
 
 
Do you know anyone, currently or in the past, involved in domestic violence?
 
Yes
 
No
 
Unsure
 
Other

 
 
 
Were you the abuser or the abused?
 
Abuser
 
Abused
 
Both
 
Both, but abused first
 
Both, but abuser first
 
Neither

 
 
 
 In the situation, could you leave or were you bound by circumstances you couldn't change or control?
 
I could and did leave
 
I was a child and didn't know I could leave
 
I couldn't leave
 
I was a child and I sought help and left
 
I was the abuser
 
Doesn't apply to me
 
Other

 
 
 
Feel free to describe other here, if you wish.
   
 
 
 
 Do you believe that alcohol or drugs played a part in the domestic violence you experienced or 
 
Yes, both
 
No, neither
 
I feel alcohol did but not drugs
 
I feel drugs did but not alcohol
 
Unsure
 
Doesn't apply to me

 
 
 
 What was the gender of the abuser?
 
Male
 
Female
 
Both
 
Unsure
 
Doesn't apply to me