Domestic Abuse Components Survey Question Title * 1. What is your age? 18-24 25-34 35-44 45-54 55-64 65+ Prefer not to specify Other (please specify) Question Title * 2. What is your ethnicity? Prefer not to answer Indigenous Black or African American White/Caucasian Filipino South Asian (e.g., East Indian, Pakistani, Sri Lankan) Chinese Japanese Latin American Southeast Asian (e.g., Vietnamese, Cambodian, Laotian, Thai) West Asian (e.g., Iranian, Afghan) Korean Arab Other (please specify) Question Title * 3. What is your self-identified gender? Cisgender female Cisgender male Trans female Trans male Non-binary Prefer not to specify Other (please specify) Question Title * 4. What is your sexual orientation? Lesbian Gay Bisexual Two-spirited Pansexual Asexual Queer Straight Other (please specify) Question Title * 5. Which of the following best describes the relationship you are referring to? (NOTE: if you have had multiple abusive partners, pick ONE to answer this survey about. You can complete the survey more than once if you have had more than one abusive partner). Abusive Unhealthy Healthy Unsure Other (please specify) Question Title * 6. My partner that I am completing this survey about is: The opposite gender as me The same gender as me Other (please specify) Question Title * 7. Which of the following types of isolation did you experience in your relationship? (Select all that apply) Verbal isolation (interference with who you are permitted to speak to or what you are allowed to say) Social isolation (Interference with your participation in social settings, which could include: education, work, spiritual gatherings, extracurricular activities, time with friends and/or family) Physical isolation (physically isolating you, which can involve having you move to a different location, or it can be physical isolation at a location like a home, and requiring you to remain in the home, or it can be confining you to a certain room, or blocking you from leaving) Psychological isolation (even though they haven't overtly said you can't do certain things or see certain people, you've noticed a pattern where you are gradually seeing people less or going places less and you have a sense that it has to do with your relationship) I did not experience any forms of isolation in my relationship Other form of isolation not listed (please specify) Question Title * 8. Please select all the aspects of your health that have been impacted by your partner. (Select all that apply) Sleep (denied or interfered with your sleep, or forced you to sleep. Also includes waking you up or engaging in other behaviours that compromise your sleep) Exercise (denied exercise or certain forms of exercise, or forced to exercise or engage in certain types of exercise) Food (denied food or certain foods or forced to eat food or certain foods) Medications (denied medications or forced to take medications) Drugs/Alcohol (denied drugs/alcohol or forced to take drugs or alcohol or sabotaged in your recovery) Spiritual (denied participating in spiritual practices or forced to participate in spiritual practices) Bathroom use (denied or interfered with your freedom to use the washroom, or forced you to use the bathroom or made you uncomfortable when using the bathroom) Personal hygiene/beauty (denied or interfered with your freedom to engage in personal hygiene/beauty rituals, or forced you to engage in certain personal hygiene/beauty rituals) My health was not affected by my partner Other aspect of my health not listed (please specify) Question Title * 9. Indicate to what extent your autonomy (your freedom to make choices about your own life) has been impacted by your partner. My autonomy (freedom to make choices) has been significantly reduced My autonomy (freedom to make choices) has been moderately reduced My autonomy (freedom to make choices) has been slightly reduced My autonomy (freedom to make choices) has not changed My autonomy (freedom to make choices) has slightly improved My autonomy (freedom to make choices) has moderately improved My autonomy (freedom to make choices) has significantly improved Other (please specify) Question Title * 10. Indicate to what extent your identity has been impacted by your partner. My identity has been significantly compromised (I struggle to know who I am anymore) My identity has been moderately compromised My identity has been slightly compromised My identity has not been compromised Other (please specify) Question Title * 11. Indicate to what extent your connection with reality has been impacted by your partner. I often feel confused about my reality I sometimes feel confused about my reality I have clarity about my reality Other (please specify) Question Title * 12. To what extent has your stability been impacted by your relationship? I more frequently feel unstable I sometimes feel unstable I do not feel unstable I feel more stable than usual Other (please specify) Question Title * 13. Manipulative Verbal Destabilization (MVD) is when your partner uses a mess of words and manipulation tactics that often lead to you feeling confused and depleted, and struggling to think clearly. It often involves drawn-out conversations that seem to go in circles and leads to you feeling unstable and confused. Has this happened in your relationship? Yes, it happens often Yes, it happens sometimes Yes, I think so No, this has not happened in my relationship Other (please specify) Question Title * 14. DARVO is a manipulation technique where a person denies or dismisses something you brought up, then attacks or accuses you of doing something wrong (blame-shifting), and then reverses the position of victim and offender (now you are framed as the offender). Has this happened in your relationship? Yes, this has frequently happened why I try to bring up concerns Yes, this sometimes happens Yes, I think this has happened No, this has not happened to me in my relationship Other (please specify) Question Title * 15. Some partners will “remove” a right, and then strategically “gift” it back to you. For example, they may refuse to let you purchase something (maybe they never allow you to buy chocolate, for example), and then one day they come home with chocolate for you. Or, they may prevent you from sleeping, and then allow you to sleep. Have you experienced this situation where your partner deprives you of a certain aspect of your freedom, and then “gifts” that freedom back to you? Yes No Please add any details you feel comfortable sharing about examples when this has occurred. Question Title * 16. Do you feel like even when you are not around your partner, your brain will echo similar criticisms that you've heard from them? Yes my brain echoes their criticisms and it significantly affects my behaviour Yes my brain echoes their criticisms and it sometimes affects my behaviour Yes my brain echoes their criticisms but it doesn't affect my behaviour No my brain does not echo their criticisms Not applicable - I generally am not criticized by my partner (except for in a collaborative, constructive way) Other (please specify) Question Title * 17. To what extent do you feel a pull similar to an addiction in your relationship? (Addiction meaning you continue to feel drawn to the relationship despite negative consequences in your life). I feel significantly addicted to them I feel somewhat addicted to them I feel a little addicted to them I do not feel addicted to them Not applicable - there are no negative consequences to them being in my life Other (please specify) Question Title * 18. Do you sometimes feel like your partner has 2 completely different sides to them? Yes No Other (please specify) Question Title * 19. Are there any other details that you would like to share about how you have been affected by your relationship? Question Title * 20. Are you willing to be contacted about further surveys? (please enter your email if you select "Yes"). No Yes Done