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Rated: 18+ · Survey Form · Adult · #1033917
A survey about Domestic Violence
I attended a forum in my town this past weekend and was shocked at the magnitude of domestic violence coursing through the veins of the world. I have decided, seeing as I, myself, am a survivor of child abuse through domestic violence, that I am going to write a book.

This survey can be answered by anyone who wants to, whether you were involved in domestic violence or if you know or knew someone involved in domestic violence or you have no links whatsoever with domestic violence.

I have made it so that this could be submitted anonymously. Know that I intend to use what is gathered here in my book so be sure to answer the last questions after thinking it through.

Thank you so much.

If you'd like, you can read my personal account, which I plan to thread throughout the chapters of the book. "My Hidden Life: A Confession" Open in new Window.
(R) denotes a required field.
You may submit your survey anonymously by checking the box to the left.
1.   Have you ever been directly involved in domestic violence?
        Yes
        No
2.   Do you know anyone, currently or in the past, involved in domestic violence?
        Yes
        No
        Unsure
3.   Were you a child who was abused or do you know a child who was or is being abused? Abuse is physical, sexual, mental and emotional. All these count as abuse!
        Yes, I was abused as a child.
        No, I wasn't abused as a child.
        Yes, I know a child who is/was abused.
        No, I don't know a child who is/was abused.
        Yes, I know of a child and I was abused as a child.
        No, I don't know of a child and I wasn't abused as a child.
        Other
4.   Feel free to expound on 'other' here.
     
5.   Were you the abuser or the abused?
        Abuser
        Abused
        Both
        Both, but abused first
        Both, but abuser first
        Neither
6.   In the situation, could you leave or were you bound by circumstances you couldn't change or control?
        I could and did leave
        I was a child and didn't know I could leave
        I couldn't leave
        I was a child and I sought help and left
        I was the abuser
        Doesn't apply to me
        Other
7.   Feel free to describe other here, if you wish.
     
8.   Feel free to share anything here that you want to. Memories, regrets, fears, doubts...this is the place to write them. This isn't mandatory.
     
9.   Do you have hope now? Have you forgiven and moved on? How did you cope, change, grow?
     
10.   Do you believe that alcohol or drugs played a part in the domestic violence you experienced or know of?
        Yes, both
        No, neither
        I feel alcohol did but not drugs
        I feel drugs did but not alcohol
        Unsure
        Doesn't apply to me
11.   Who was the abuser?
        Spouse
        Parent
        Significant Other (not married, not living together)
        Significant Other (not married, living together)
        Sibling
        Relative
        Other
12.   Who, if 'other' selected above, was the abuser?
     
13.   What was the gender of the abuser?
        Male
        Female
        Both
        Unsure
        Doesn't apply to me
14.   What was the gender of the abuse victim?
        Male
        Female
        Both
        Unsure
        Doesn't apply to me
15.   If you were directly involved in domestic violence and/or child abuse, how do you see yourself now?
        Survivor
        Victim
        A little of both
        Neither
        Unsure
        Doesn't apply to me
16.   Did you go through counseling after the abuse became known?
        Yes
        No
        Yes, alone
        Yes, with abuser
        Yes, I was a child
        Yes, I was the abuser
        Other/Doesn't apply to me
17.   Do you believe the counseling helped you deal with the abuse and move on?
        Yes, very much so
        Yes, only slightly
        No, not really
        No, not at all
        Still in counseling
        Unsure
        Other/Doesn't apply to me
18.   How do you feel today, regardless if still in abusive situation, recently emerged or free for a long time?
        Fine
        Bitter
        Forgiving
        Guilty
        Unloved/Unworthy
        Ugly
        Other
19.   Describe 'other' or expound on feelings not listed above, if you'd like.
     
20.   Did you find that the abuse changed you for the worse?
        Yes, I'm more angry now
        Not really
        Yes, I have begun abusing others now
        No, I refuse to let it
        Doesn't apply to me
21.   What advice could you offer? What advice would have helped you leave? What advice could you use now, if you are currently in a domestic abuse situation?
     
22.   Would you mind if I used the personal information you shared in my book?
        Please feel free to use my comments
        Please do not use my comments
        Unsure. Please check back with me before seeking publication.
23.   Consider carefully. Would you like your name to appear in the acknowledgements in the book and/or with your comments?
        No, thank you
        Yes, but only in the acknowledgements
        Yes, in both the acknowledgements and with my comments
        Unsure. Please check back with me before seeking publication
24.   If you said that you would like your name in the book for any reason, or if you answered unsure, include name here and/or email address, especially email if you did this survey anonymously and you want me to email you.
     
25.   Feel free to express your thoughts, ideas and comments here. I am open to suggestions about this survey. Thank you.
     

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