Couples Therapy Pre-Screen | Miller Counseling

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Part I Immediate Safety Screen

Please answer Yes or No.

1.Do you currently feel afraid of your partner?

Yes No

2.Do you ever change your behavior, appearance, communication, or activities because you are afraid of how your partner will react?

Yes No

3.Has your partner ever threatened to kill you, seriously hurt you, or themselves if you leave or end the relationship?

Yes No

4.Has your partner ever physically hurt you?

Yes No

5.Has your partner ever choked, strangled, suffocated, or restricted your breathing?

Yes No

6.Has your partner ever used or threatened to use a weapon against you?

Yes No

7.Has your partner ever prevented you from leaving a room, home, vehicle, or other location?

Yes No

8.Has your partner ever physically prevented you from ending the relationship or leaving?

Yes No

9.Are you currently afraid that answering these questions honestly could result in retaliation?

Yes No

10.Do you believe your partner may become more dangerous if they learn that you disclosed concerns about the relationship?

Yes No

If you answered yes to any of the questions above, please know that support is available. National Domestic Violence Hotline: 1-800-799-7233 · thehotline.org

Part II Physical or Threatening Behavior

Check all that apply. Has your partner ever:

If yes, briefly describe what occurred, when it last occurred, and whether the behavior is becoming more frequent or severe:

Part III Coercive Control & Intimidation

Does your partner:

Part IV Emotional & Psychological Abuse

Has your partner:

Part V Sexual & Reproductive Coercion

Has your partner ever:

Pressured, guilted, intimidated, or coerced you into sexual activity Continued sexual activity after you communicated that you wanted to stop Ignored your refusal or inability to consent Used physical force during sexual activity without your consent Threatened the relationship, finances, housing, or other consequences if you refused sex Prevented you from using contraception or interfered with contraception Pressured you regarding pregnancy, abortion, or whether to have children Forced or pressured you to engage in sexual activity with another person Shared or threatened to share intimate photographs, videos, or information without your consent

If yes, describe only what you feel comfortable documenting:

Part VI Financial & Material Control

Does your partner:

Control most or all household finances in a way that limits your access to money Prevent you from having access to your own income or bank accounts Monitor your spending excessively Prevent or interfere with your ability to work or attend school Prevent or limit your access to transportation or a vehicle Accumulate debt in your name without your consent Threaten to withhold housing, food, transportation, medication, or other necessities Use financial dependence to prevent you from leaving the relationship

Part VII Technology, Surveillance & Stalking

Has your partner ever:

Part VIII Children, Pets & Other Vulnerable Persons

Has your partner ever:

Threatened to harm a child or another person you care about Used children to obtain information about you or monitor you Threatened to take the children away in order to control you Interfered with your parenting or caregiving in a threatening or controlling manner Harmed, threatened, neglected, or intimidated a pet or animal important to you Threatened to harm a pet if you leave or do not comply

Part IX Substance Use & Escalation

Does either partner's substance use appear connected to any of the following:

Increased verbal aggression Threats or intimidation Physical aggression Sexual coercion Destruction of property Dangerous driving Increased jealousy or paranoia Unpredictable or escalating behavior Greater difficulty respecting boundaries

Has violence, intimidation, or coercive behavior become more frequent, severe, or unpredictable over time?

No Yes Unsure

Part X Conflict & Mutuality

These questions help distinguish ordinary relationship conflict from situations involving fear or coercive control.

Part XI Personal Perception of Safety

Please answer privately.

Additional Anything else you want me to know

Optional. Share only what you feel comfortable putting in writing.

Couples Therapy Safety Pre-Screen

Pre-screen received.