You may submit your survey anonymously by checking the box to the left.

1.   Are you male or female?

      Female Male

2.   I have experienced at least one form of child abuse. If you have, check the box to agree. If you have not, STOP! Please do not take this survey. (R)

      Check this box to agree with the above statement.

3.   If yes, What Form of Abuse?
If no, this survey is not for you. Please feel free to find a survey that is more appropriate for you.

        Sexual Abuse
        Verbal/Mental Abuse
        Physical Abuse
        Neglect
        2 forms from above.
        More than 2 forms.
        All of the above.

4.   If you chose more than one type of abuse, please be specific.

     

5.   Who did this to you? You may be brief, or detailed.

     

6.   How old were you when this happened?
Again, be as brief or detailed as you wish.

     

7.   Did you ever tell an adult you could trust about this abuse?

        Yes.
        No.
        I Tried To.

8.   If you answered you tried, please explain what happened when you tried to get help.

     

9.   How have you handled your experiences with abuse?
ie: counseling, talking with friends,journaling,writing...

     

10.   I've created a forum for survivors of childhood abuse. Would you be interested in posting and participating in this forum?

      Yes! No, thank you. I'd like to read posts first. I might give it a try.

11.   I'm exploring writing a book with others. This would include detailed accounts of your experiences. Would you be interested, if I was able to do that?

      Definitely! No, it's too private to share. I'm not sure.

12.   Do you have anything you would like to ask me?

     

13.   Do you have anything you want to tell me? Perhaps I missed a question that you would have liked to answer. Was this survey helpful for you?

     

14.   If in the USA, what state are you in?
Please see #15 if you are in another country.

     

15.   If outside the USA, what country are you in?

     

16.   Would you like to be added to this group?

632338

Affected By Abuse  [18+] Have You Been Affected by Childhood trauma? Join Our Group, We Can Help! By: S.L. Stiles is ink Blottin'

(R)

        Yes, add me, please!
        Not right now, thanks.
        Let me get back to you on this.

17.   How old are you now? This is not required, but it is very helpful. Especially, I need to know if you are a child.

        Under 18
        18-25
        26-35
        36-40
        41-50
        Over 50

18.   If you elect to be added to one of both support groups, what are you willing to do to help yourself? Also, what would you like to accomplish from being a member of the group(s)?

     

19.   What problems do you have now, or have you had that you believe are attributed to the abuse you endured? Examples: Anger, depression, feelings of wanting it all to end, 'coping methods', etc. Any and all examples you can give are extremely helpful.

     

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      Enter the number of Gift Points to be sent:
      Confirm this Gift Point amount by re-entering:
      (From a minimum of 100 to a maximum 250,000 Gift Points.)

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Disclaimer: The information that you are submitting with this survey form is being sent to UY... . It is NOT being sent to Writing.Com. You should be careful to not submit any information which you may deem as private or confidential. Writing.Com and its affiliates will not and may not be held responsible or liable, in any way, for any damages that may or may not arise from your submission of this form.