Emotional Abuse Questionnaire

June 13, 2011

An emotional abuse questionnaire is one that aims at testing whether an individual is undergoing such a predicament. The questions assist the counselor to determine the level of abuse and the reasons behind the abuse.

An emotional abuse questionnaire also helps in revealing the extent of the damage caused psychologically to the patient. With the help of the questionnaire the doctor or counselor can trace the source of the abuse.

An emotional abuse questionnaire helps the doctor or counselor to prescribe proper medication or take necessary action to treat the patient. The subtle approach of the questionnaire also helps the patient to share information he hasn’t shared before.

Sample Emotional Abuse Questionnaire

  1. Does your partner/colleagues/friends try to trap you to do things to show that you are not a good person?_________________________________________________________
  2. Has anyone soiled your name among friends /colleagues or relatives by saying negative things about you?_______________________________________________________
  3. Does anyone tell other people that you don’t behave normally and that your character is suspicious?_____________________________________________________________
  4. Has anyone said physically abusive things to you, e.g. you are ugly? Or you are not smart?_____________________________________________________________
  5. Do people insult your religious inclination by saying bad things about your religion?_________________________________________________________
  6. Do people discriminate you because of your ethnic background? If so, how._________________________________________________
  7. Does anyone have a tendency of humiliating you in front of other people?_______________________________________________
  8. Have you given personal information to someone who disclosed it to other people?____________________________________________
  9. Have you ever been to a hospital or an institution as a result of emotional problem?________________________________________________
  10. Has anyone ever complained about conduct being abnormal?_______________________________________________________
  11. Have you taken any medication for emotional purposes? _______________

Download Emotional Abuse Questionnaire in Word Format

Top Sample Questionnaire:

{ 2 comments… read them below or add one }

Kim Brooks June 15, 2011 at 4:05 pm

I am trying to find information on proving that someone was abused over an 18 month period of time by her spouse . The continued emotional, mental & economic/financial abuse over this period of time resulted in a deterioration of her overall phsyical health. The emotional questionaire above is helpful, are their other’s for the mental,psychological or economical as well, perhaps a checklist? She is currently in pursuit of a divorce & we want to make sure that “this is what we think it is”, that is why we are trying to find all of these forms. Any suggestions or information would be appreciated & most helpful.
Thank You


asma gillani February 2, 2013 at 3:43 pm



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