Beyond the Silence Questionaire

Beyond the Silence Questionnaire

Contact Information
Date

MonthDayYear
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
E-mail
EmailPhoneText Message

Emergency Contact
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number

Church
YesNo
If yes, which campus do you usually attend?
If yes, which service do you usually attend?
YesNo
If you attend another local church, what is the name of that church?
Of the following options which campus and night would you like to attend this group?

Past Experience
YesNo
If so, what are the relationship(s) of the person(s) you shared your story with?
What was the relationship of your first offender?
How old were you the first time you were sexually abused?
How long ago was the last time you were sexually abused?
Do you remember the sexual abuse?

Mental Health
Post Traumatic Stress DisorderDissociative Identity DisorderBorderline Personality Disorder
YesNo
If yes, what is the name of the mental health condition?
YesNo
YesNo
Please explain.
What would you most like to get out of attending the Beyond the Silence sexual abuse recovery care group?
Should be Empty: