Please indicate if any of the following has happened to you or anyone you know:
| Yes | No | Uncertain | |
|---|---|---|---|
| Experienced verbal, mental, or physical abuse | |||
| Hospitalized for injuries resulting from abuse | |||
| Felt life was seriously threatened by abuser if attempt to leave was made |
Did you know that...
| Yes | No | |
|---|---|---|
| In order for a restraining order to be truly effective you must ENFORCE it? | ||
| Shelters and other domestic violence programs will not reveal your identity under any circumstances? | ||
| Shelters and domestic violence programs not only provide counseling but support in legal matters as well? |
Please provide us with some information about yourself and what other suggestions you may have for our page on domestic violence.
| Gender: | Male | Female |
Age:
Highest Level of Education Completed:
Please make any suggestions or comments about our page:
Please submit the survey when you are done. Thank you.
