1. Healing Voices Survey

Healing from assault or abuse can be hard. Our crisis center and legal services are here to help. We want to hear from survivors about what it is like to receive services. Hearing survivor voices will help us make things better for all survivors in our community and throughout Mississippi.

If you are willing to share your experiences, simple complete this short questionnaire.
-Your name will not be written anywhere on this paper unless you desire it
-You can skip any questions you don't want to answer.
-Your advocate or attorney will not see your individual answers.

If you do not want to share your experiences, you can recycle this form. If you answer some of the questions and then change your mind you can stop taking the questionnaire. You can still receive help from this center even if you do not answer these questions.

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* Your Name (Optional)

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* Date Survey Completed

Date

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* Date Admitted to Program

Date

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* Date Exiting Program

Date

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* What county do you live in

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* I identify as...

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* I identify as...

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* Which category below includes your age?

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