Parent’s Self Survey: Children’s Exposure to Violence and

Abuse
Experience has shown that children who have been exposed to violence
and abuse can suffer many of the same difficulties of children who have
been directly abused. The following questionnaire is designed to help
you identify the exposure of your children or your partner’s children to
abuse and violence in the home.

1. Are your children’s daily routine Never Occasionally

interrupted by arguments between Frequently
yourself and your partner?

2. Have your children heard you call Never Occasionally

your partner a name or put him or her Frequently
down?

3. Have you directed negative Never Occasionally

comments about your partner to your Frequently
children?

4. Have you threatened your partner Never Occasionally

with taking the children away from Frequently
her or him?

5. Have the children tried intervening Never Occasionally

when you have been physically or Frequently
verbally abusive to your partner?

6. Have your children been in the house Never Occasionally

when you have been physically Frequently
abusive to your partner?

7. Have your children seen the physical Never Occasionally

damage to property following a Frequently
violent incident?

8. Have your children ever seen physical Never Occasionally

injuries to an adult following a violent Frequently
incident?

9. Has your abuse ever led to the loss of Never Occasionally

work time and income for the family Frequently
for either you or your partner?

10.Have your children ever lost time No Yes

with you because of a separation,
divorce or incarceration related to
your violence?

11.Have your children ever Never Occasionally

 demonstrated fear in reaction to your Frequently
behavior in the household?

12.Do your children have any learning No Yes

problems, difficulties in school,
emotional problems, or behavior
problems that might be related to
their exposure to your abuse at
home?

If you answered “yes,” “occasionally,” or “frequently” to any of these questions your

children may be receiving negative consequences from your behavior.
2001 Revised 2002 The Non-Violence Alliance 353 Main Street Middletown, CT
06457