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Your truth
will help other survivors.
- Cosima Zehring
Questionnaire
The goal of this questionnaire is to help survivors of child abuse,
rape and domestic violence. The results from the questionnaire
will be used in two primary ways:
-
As a book for survivors who are
transitioning from realizing it wasn't their fault to becoming whole
and reclaiming their lives.
-
As material for professionals to gain an
in depth understanding of the healing process and to provide more
focused care to their clients.
There are no right answers. Please answer as honestly and as
completely as possible. There are 90 questions over eight pages with
each page containing nine to twelve questions. Feel free to skip any
questions that you can not or do not want to answer. At the end of each
page, your answers are submitted, so you don't have to complete the
entire questionnaire in one sitting. For example, if you only have time to complete the
first three pages, you can return later and complete the last five
(submit blank pages for the first three then continuing your
questionnaire by answering the questions on the last five pages).
Thank you in advance for your time and your honesty.
- What is your gender?
Male
Female
Trans-gender
- What is your age?
- How were you abused (check all that apply):
Verbally
Emotionally
Spiritually
Physically
Sexual Molestation
Rape
Mentally
Not Sure
Neglected
Abandoned
Alcoholism or Drug Use in Family
Other
- At what age did the abuse start?
- Who abused you? (check all that apply):
Parent or Parent-figure
Grandparent
Uncle/Aunt
Cousin
Sibling
Other Relative (by blood or marriage)
Friend or Friend of Family
Pastor/Priest/Spiritual Leader
Neighbor
Caregiver (teacher, babysitter,
coach, etc..)
Stranger
Acquaintance
Not Sure
Other
- How do you feel about the abuse now? (check all that apply):
Numb
Guilty
Ashamed
Dirty
Angry
Frustrated
Hurt/Upset
Damaged
Forgiving
Afraid
Enraged
Grief-stricken
Proud
Stronger
Other
- How many people have you told about the abuse?
No one
One
Two
Three
Four
Five
Six
Seven or more
Everyone I can
- Have you told your parents? If yes, how did you tell them and
how did they react? If no, why not?
- Have you told your significant other about the abuse?
Yes
No
Don't have a significant other
- Is there someone in your life you'd like to tell about the abuse but
haven't?
Yes
No
- Do you feel like you are keeping a secret if your friends, significant
other or other important people in your life don't know?
Yes
No
- Are you nervous or hesitant to tell new people in your life about the
abuse?
Yes
No
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