TGH Survey – teal green heart

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Survivor's Survey

First name

Last name

Phone

Phone country code (If outside of U.S.)

Address

Zip code/postal code

City

State

Country

Date of birthdate (mm-dd-yyyy)

Country of origin

Nationality

Race / Ethnicity

Gender

Sexual preference

Are you willing to participate in a noninvasive research study that includes traditional talk therapy?

Do you have any siblings?

How many Girls?

How many Boys?

Do you have support to help with your rape recovery?

Who will help and listen?

Who should we contact in the event of an emergency? Name

Emergency contact’s number

What is your highest education level

Share your feelings
Please share how you feel by choosing one statement that closely matches how you’ve been feeling in the past week. Don’t take too long over your replies, as your immediate answers are most accurate.
How Do you feel right Now?

I feel tense or wound up

I still enjoy the things I used to enjoy:

I get a sort of frightened feeling as if something awful is about to happen:

I can laugh and see the funny side of things

Worrying thoughts go through my mind:

I feel cheerful:

I can sit at ease and feel relaxed:

I feel as if I am slowed down:

I get a sort of frightened feeling like 'butterflies' in the stomach:

I have lost interest in my appearance:

I feel restless as I have to be on the move:

I look forward with enjoyment to things:

I get sudden feelings of panic:

I can enjoy a good book or radio or TV program:

Sexual assault information
Where you sexually?

What country did the rape occur in?

What state in the U.S. did the rape occur in?

Were you a survivor of any of the following?

Is the person who hurt you one of your caregivers?

Did your spouse sexually abuse you?

Did you file a restraining order against the person who hurt you?

Did you know the person before the sexual assault or rape occurred?

Did the person who hurt you, do drugs or drink alcohol in front of you?

At any time did you ever give consent and/or later change your mind before the assault?

Were you physically awake and/or coherent to provide consent?

Is it possible, you were intoxicated and/or a drug was put in your drink?

Did you see the beverage prepared and poured into a glass before you drank it?

Were you drinking at a different location and taken to a separate and/or secluded/discrete location and assaulted or raped?

Were you on a date?

Was this your first date with the offender?

Did your ex-boyfriend commitment the sexual assault or or rape against you?

Did an estranged ex-companion commit the sexual assault against you?

Did a random stranger commit the sexual assault or rape against you?

Did you tell anyone about the sexual assault or rape that occurred against you?

Who did you tell?

Did you ask the person you told to keep the sexual assault or rape a secret?

What is the first name (if known) of the 1st person(s) who assaulted, attacked, battered or raped you?

What is the last name (if known) of the 1st person(s) who assaulted, attacked, battered or raped you?

What time of day did the crime occur am or pm?

Were you physically disfigured from the crime?

What time did you escape from the environment am or pm?

Do you feel comfortable telling your story to a rape advocate or counselor ?

Did you report the sexual assault or rape to the police?

Was an official police report made

Did a detective from the police department meet with you to investigate the matter after you filed the police report?

In what time frame did you report the incident?

In what city and state and/or country did the sexual assault or rape occur?

Was the local police department quick to respond?

Did the police department conduct a thorough investigation?

Was the accused arrested or asked to come to the police station, and/or questioned regarding your police report

Was the suspect arrested, charged, and convicted?

Did you receive criminal restitution/victim Of crime resources?

Did the convicted criminal serve anytime for the sexual assault or rape committed against you?

Were you notified when the suspect Is Released?

When your case was over and/or the suspect was released was there a protective order established?

After the investigation and/or prosecution, were you offered any assistance or restitution from the police, or local/state agencies?

Select all of the recovery programs or therapies that helped you:

How long did it take you to mentally recover from the sexual assault and/or rape trauma?

Which is the name of the person, programs or agency that helped you to get better?

Are you familiar with VAWA (Violence Against Women Act)?

Have you ever participated in programs funded by VAWA (Violence Against Women Act)?

On a scale of 1 to 10 (1 being the lowest and 10 being the greatest) how would you rate your recovery progress after a month of participation in your local government’s recovery program?

On a scale of 1 to 10 (1 being the lowest and 10 being the greatest) how would you rate your recovery progress after 2 months of participation in your local government’s recovery program?

On a scale of 1 to 10 (1 being the lowest and 10 being the greatest) how would you rate your recovery progress after 3 months of participation in your local government’s recovery program

Do you think, you require or required additional time to fully recover?

Rape treatment
Did you receive talk therapy with an accredited and experienced therapist?

What is the name of the rape counselor or rape facility where you received counseling?

How long did you receive counseling?

Did you receive any other type of treatment to help process the criminal trauma?

Did you receiving or have you received counseling prior to sexual assault or rape incident?

How many times have you been sexual assaulted or raped?

After the sexual assault or rape incident, were you prescribed medications?

Were you prescribed mental medications prior to rape or sexual assault incident?

What country did the rape occur?