Domestic Abuse Back Sheet

lied about me to the police	lied about me to a court	assaulted me in a vehicle
raged at me in a vehicle	withheld my medication	stole my medication
destroyed my medication	tainted my medication	withheld my property
stole my property	damaged my property	destroyed my property
withheld our property	stole our property	damaged our property
destroyed our property	opens my personal mail	steals my mail
changed locks to our home	locked me out	changed our phone number
changed our bank account	ran up credit charges	hides unpaid bills
threatens to leave	prevents me from sleeping	erratic mood swings
threaten to hit me	threaten to kill me	tortured or killed family pet
threaten to harm child(ren)	used child(ren) as a shield	threatens to take children
uses child(ren) as a shield	threatens suicide	self-inflicted injuries
staged suicide	physically abused me	sexually abused me
orders me to leave	threatens false DV charges	orders me to obey her
false allegations of adultery	isolates me from others	constant belittlement
constant nagging	constant yammering	constant tirades and rages
threatens to ruin me	threw things at me	used a weapon against me
eats all of our food	threatens revenge if I tell	threatens to call the police

[ ] This abuse occurred in the presence of [ ] a child [ ] of children. (Names are optional)

[ ] I believe that the abuser is a danger to [ ] the child(ren) [ ] to me [ ] to others [ ] to her/himself