Domestic Violence Survey (Confidential)

Domestic Violence Survey (Confidential)

Your responses are confidential and will be used to better understand your needs and provide the appropriate services and support.
Date*

MonthDayYear
Date
Personal Information
Name*

First NameLast Name
Date of Birth:

MonthDayYear
Date
What is your gender?*

FemaleMalePrefer not to say
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Would you like to receive text messages or emails from the F.A.I.T.H. Connection Center Inc.?*

Yes, I would like to receive text messages.Yes, I would like to receive emails.No, I do not wish to receive text messages or emails.
Current & Past Situation(s)
Are you currently experiencing domestic violence?

YesNo
Did you know that women and children are not the only victims of domestic violence. Men can also be victims of domestic violence?

YesNo
What type of domestic violence have you experienced? (Check the most recent)*

I have not been the victim of domestic violencePushing or shoving (causing no injury)Pushing or shoving (with injury)Hitting, slapping punching causing injuryKickingPulling hairUsing a source of an object to hit youAttempt of strangulationBeen burntOther
Which of type of domestic violence are you experiencing now?*

Sexual Abuse: This includes any form of sexual violence, coercion, or unwanted sexual acts.Financial Abuse: Controlling or restricting access to money, preventing the victim from working, or taking away their financial independence.Spiritual Abuse: involves the manipulation or control of someone through the misuse of religious or spiritual beliefs and practices.Neglect: Withholding food, medical care, or shelter as a means of control or manipulation.Reproductive Coercion: This involves sabotaging birth control, forcing pregnancy, or pressuring the victim to have or not have children against their will.Physical Abuse: This includes hitting, slapping, punching, kicking, or any other physical violence.Stalking: Repeatedly following or watching someone in a way that causes them fear or distress.Isolation: Attempting to isolate the victim from friends, family, or any support systems, making them more dependent on the abuser.Digital/Technological Abuse: Using technology to stalk, monitor, control, or harass the victim. This can include tracking apps, controlling social media, or threatening online exposure.Verbal Abuse: Name-calling, yelling, insulting, and using words to belittle or control the victim.Emotional/psychological Abuse: This involves manipulation, threats, humiliation, or constant criticism aimed at undermining the victim’s self-esteem and mental health.Don't wish to discuss
What is the relationship between the abuser and the victim?*

Boyfriend / GirlfriendHusband / WifeLiving with themFamily memberOther
Are you currently in a safe environment?*

YesNoNot Sure
Was the abuser Male or Female ?*

MaleFemale
Did you know that children who experience domestic violence are more likely to be adult perpetrators?*

YesNo
If you are the victim, do you know where to go?*

Friend'sWomen's refugeeOrganizationsPoliceSocial servicesChurch LeaderWith a trusted Family memberOther
Support Services and Resources
What type of support or services are you seeking from F.A.I.T.H. Connection Center Inc.? (Check the most important to do first for you)*

Emergency shelterCounseling or therapySafety planningSupport groupsSocial servicesLife coachingLegal assistanceFinancial assistanceHousing supportJob training or employment assistanceChildcare assistanceSpiritual supportOther
Are you interested in spiritual support, prayer, or faith-based counseling?*

YesNoNot sure
Do you need help accessing any of the following basic resources? (Check one)*

FoodHygiene ProductsClothingHousing/ShelterTransportationMedical/Health ServicesFinancial assistanceLegal AssistanceIncome/Benefits AssistanceSpiritual supportOther
Safety and Emotional Support
Would you like assistance with developing a safety plan?*

YesNo
Do you feel that your current environment is emotionally and physically safe?*

YesNoNot sure
Have you ever sought help from a domestic violence shelter or support service before?*

YesNo
Life Coaching & Personal Development

Would you be interested in learning more about or joining any of the following organizations for additional support and services? (Check all that apply)
Alisha Jackson Academy – Offers courses and coaching to empower personal growth and transformation.*

Yes, I would like more information on joining Alisha Jackson Academy.No, I am not interested at this time.
Divine Warrior Life Coaching – Provides life coaching and guidance to help you overcome challenges and achieve your goals.*

Yes, I would like more information on joining Divine Warrior Life Coaching.No, I am not interested at this time.
Alisha Jackson Ministries – Offers spiritual support, prayer, and healing through ministry services.*

Yes, I would like more information on joining Alisha Jackson Ministries.No, I am not interested at this time.
A Better Life Publishing Company – Helps individuals share their stories and experiences through books and publications.*

Yes, I would like more information on joining A Better Life Publishing Company.No, I am not interested at this time.
What areas of personal growth or healing would you like to focus on? (Check one)*

Building self-esteemHealing from traumaGoal settingStress managementConfidence buildingEmotional regulationOther (Explain below)
Other:
Would you like to receive follow-up information via email or phone about the services provided by any of the above organizations?*

Yes, I would like to receive follow-up information.No, I prefer not to receive follow-up information.
Preferred Method of Contact:*

EmailPhoneEither is fine
Feedback & Improvement
How would you rate the support you received from F.A.I.T.H. Connection Center Inc.?*

ExcellentGoodNeutralPoorVery PoorOtherNot applicable
Do you feel that the staff treated you with respect, kindness, and empathy?*

YesNoNot sure
Would you recommend F.A.I.T.H. Connection Center Inc. to someone else in need of domestic violence services?*

YesNoNot sure
How would you rate your overall satisfaction with your current situation?*

Very SatisfiedSatisfiedNeutralDissatisfiedVery Dissatisfied
Do you feel like your current needs are being met?*

YesNoPartially
Are there areas in your life where you need additional support?*

YesNo
If yes, please specify:
Since using our service, have you noticed any improvements in your situation?*

YesNo
If yes, please explain:
What was the most valuable aspect of the service?*
Additional Information
Would you be interested in participating in future surveys or feedback sessions?*

YesNo
Is there anything else you would like to share about your experience or needs?
Consent and Acknowledgement
By signing below, I acknowledge that the information provided is accurate to the best of my knowledge. I understand that the purpose of this form is to help connect me with the services and resources that best meet my needs.
Signature*

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Thank You!
Your feedback is important to us and helps us improve the services we provide. If you need immediate assistance, please contact us directly at 1-888-850-7790 or Admin@FaithConnectionCenter.org.
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Domestic Violence Survey (Confidential)

Personal Information

Current & Past Situation(s)

Support Services and Resources

Safety and Emotional Support

Life Coaching & Personal Development

Feedback & Improvement

Additional Information

Consent and Acknowledgement

Thank You!