EmpowerHer: Domestic Violence Support Group
"You are never alone"
Name
First Name
Last Name
Email
example@example.com
Which category below includes your age below?
under 15
15-19
20-30
31-40
41-50
51-64
65and over
What is your gender?
Female
Male
Prefer not to say
Which of the following types of domestic abuse do you know?
Physical
Sexual
Mental / Emotional
Have you or anyone you know suffered from domestic violence?
Yes
No
What type of domestic violence have you or someone you know experienced?
I have not been the victim of domestic violence
Pushing or shoving (causing no injury)
Pushing or shoving (with injury)
Hitting, slapping punching causing injury
Kicking
Pulling hair
Using a source of an object to hit you
Attempt of strangulation
Been burnt
Other
How was her/his relationship with the abuser?
Boyfriend / Girlfriend
Husband / Wife
Living with them
Family member
Other
Was the abuser Male or Female ?
Male
Female
If you were your victim, where would you go?
Family
Friend's
Women's refugee
Organisations
Police
Social services
Church Leader
Other
Do you feel comfortable sharing your experiences with the group?
Yes
No
What does healing mean to you?
Please add your additional notes if you want to
Submit
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