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This assessment helps R.I.S.E. Consulting, LLC document the pattern and impact of abuse in your relationship or situation, to support a report for your attorney or the court. It is not a psychological evaluation and does not diagnose any condition.
This intake is completed as part of forensic victimology, human behavior analysis, and litigation consulting services provided by R.I.S.E. Consulting, LLC. It is not a psychological or psychoeducational evaluation. Any checklist or index scores are descriptive self-report data, not clinical diagnoses — only a licensed mental health professional can make a clinical diagnosis. Answer as honestly and completely as you can; there are no right or wrong answers.
Not a client with an active case? You may prefer our free, private Relationship Awareness Questionnaire — nothing you enter there is saved or sent anywhere.
Select the response that best describes your experience with each item.
1. Physical abuse (hitting, pushing, restraining, choking, throwing objects, etc.)
2. Psychological or emotional abuse (insults, humiliation, threats, degradation)
3. Cruelty (deliberate acts intended to demean, frighten, or cause suffering, including cruelty toward pets or possessions you valued)
4. Coercive control (isolation, monitoring, restricting movement, decisions, or finances)
5. Financial exploitation or abuse (controlling access to money, incurring debt in your name, sabotaging employment)
6. Destruction of property (damaging belongings, home, vehicle, or sentimental items)
7. Digital or technological abuse (tracking, monitoring devices/accounts/location, impersonation)
8. Sexual abuse or coercion
9. Threats against children, pets, or family members
10. Stalking, surveillance, or harassment (including post-separation)
11. Immigration-related threats or control
12. False allegations or misuse of protective/legal systems against you (e.g., false police reports, weaponized protective orders, threats of false charges)
13. Isolation from friends, family, or support systems
14. Reputational harm or attempts to damage your standing (workplace, community, custody proceedings)
These prompts explore barriers to disclosure and system-response issues common for, though not unique to, male-identifying survivors. They are exploratory, not diagnostic.
Public-domain CDC/Kaiser screening tool. A descriptive count (0–10) of childhood adversity categories — not diagnostic.
1. Did a parent or other adult in the household often swear at, insult, put down, or humiliate you?
2. Did a parent or other adult in the household often push, grab, slap, or throw something at you, or ever hit you hard enough to leave marks?
3. Did an adult or person at least 5 years older ever touch or fondle you, or have you touch their body in a sexual way?
4. Did you often feel that no one in your family loved you or thought you were important?
5. Did you often feel that you didn't have enough to eat, had to wear dirty clothes, or had no one to protect you?
6. Were your parents ever separated or divorced?
7. Was a parent or other adult in the household often pushed, grabbed, slapped, or had something thrown at them, or sometimes/often kicked, bitten, hit, or threatened with a weapon?
8. Did you live with anyone who was a problem drinker, alcoholic, or who used street drugs?
9. Was a household member depressed, mentally ill, or did a household member attempt suicide?
10. Did a household member go to prison?
Documents self-reported depressive symptoms you associate with the abuse or its aftermath. Descriptive only, not a diagnosis.
1. Persistent sad, down, or empty mood
2. Loss of interest or pleasure in activities once enjoyed
3. Significant changes in appetite or weight
4. Fatigue or noticeable loss of energy
5. Feelings of worthlessness, guilt, or self-blame
6. Difficulty concentrating, thinking, or making decisions
7. Noticeable slowing or restlessness in movement or speech
8. Recurrent thoughts of death, dying, or self-harm
9. Withdrawal from friends, family, or usual activities
10. Frequent tearfulness or crying spells
11. Feeling hopeless about the future
12. Loss of motivation to complete daily tasks or responsibilities
Documents self-reported anxiety symptoms you associate with the abuse or its aftermath. Descriptive only, not a diagnosis.
1. Persistent worry or fear that is difficult to control
2. Restlessness or feeling keyed up / on edge
3. Muscle tension or physical tightness
4. Racing heart, chest tightness, or shortness of breath
5. Trembling, shaking, or feeling faint
6. Sweating, hot/cold flashes, nausea, or stomach distress
7. Difficulty concentrating due to worry or fear
8. Increased irritability
9. Avoidance of people, places, or situations connected to the abuse
10. Panic episodes (sudden, intense fear with physical symptoms)
11. Hypervigilance, scanning for danger, or exaggerated startle response
12. Fear reactions to reminders of the perpetrator (sounds, smells, locations, dates)
Documents self-reported sleep disruption. Descriptive only.
1. Difficulty falling asleep
2. Difficulty staying asleep or frequent waking during the night
3. Nightmares specifically related to the abuse or relationship
4. Other disturbing or fear-based dreams
5. Waking in a state of fear, panic, or physical arousal (racing heart, sweating)
6. Sleeping significantly more than before the abuse began
7. Avoiding sleep due to fear of nightmares or of being caught off guard
8. Daytime fatigue or exhaustion attributed to poor sleep
9. Use of medication, alcohol, or other substances to fall or stay asleep
10. Sleep disruption interfering with work, caregiving, or daily functioning
A descriptive count of self-reported life impacts, modeled on the same non-diagnostic design as the ACE questionnaire above. Not a clinical diagnosis.
1. Disruption to sleep patterns since the event
2. Avoidance of places, people, or activities connected to the event
3. Difficulty concentrating at work or school since the event
4. Withdrawal from relationships or social activities
5. Increased irritability or conflict in relationships
6. Physical health changes (appetite, energy level) since the event
7. Financial disruption connected to the event
8. Loss of employment or reduced work capacity connected to the event
9. Housing instability connected to the event
10. Changes in relationship with children or family connected to the event
11. Changes in substance use since the event
12. Repeated intrusive memories of the event
13. Heightened startle response or hypervigilance
14. Loss of interest in previously enjoyed activities
15. Self-reported feelings of hopelessness or a diminished outlook on the future
Check what you currently have, what you'd like help requesting, or mark not applicable.
1. Police reports
2. Protective order documentation
3. Medical records
4. Photographs
5. Text/email/communication records
6. Employment or financial records (for financial exploitation claims)
7. Records of false allegations or prior legal filings by the alleged abuser
Your responses are not sent anywhere automatically. You can download or print a copy for yourself, email it to R.I.S.E. Consulting, or submit it securely below — it is then delivered directly to Dr. Merizier's team and is not visible to anyone else.
This tool is descriptive and non-diagnostic. It does not evaluate for PTSD, depression, anxiety, or any other medical or psychological condition. Responses are not sent anywhere unless you choose to download, email, or submit them.