Verbal Abuse Assessment Form
Help us understand your experiences by completing this confidential assessment.
Your Full Name
First Name
Last Name
Your Age
*
Your Gender
*
Female
Male
Non-binary
Prefer not to say
Other
Your Relationship to the Person Involved
*
Family member
Partner/Spouse
Friend
Colleague
Supervisor/Manager
Other
Where does the verbal abuse most often occur?
*
Home
Workplace
School
Online
Public spaces
Other
How frequently do you experience verbal abuse?
*
Daily
Weekly
Monthly
Occasionally
Rarely
Types of Verbal Abuse Experienced
*
Rows
Never
Rarely
Sometimes
Often
Always
Insults or name-calling
1
2
3
4
5
Threats or intimidation
6
7
8
9
10
Yelling or shouting
11
12
13
14
15
Blaming or shaming
16
17
18
19
20
Humiliation in front of others
21
22
23
24
25
Manipulation or gaslighting
26
27
28
29
30
How much has verbal abuse affected your emotional well-being?
*
No impact
1
2
3
4
5
6
7
8
9
Severely impacted
10
1 is No impact, 10 is Severely impacted
Have you sought help or support for this situation?
*
Yes
No
Prefer not to say
Please describe any additional details or experiences you wish to share.
Submit Assessment
Should be Empty: