Your details (please complete) -
Your Email
address Essential, if
you are wanting us to reply to you.
Your
Email address is really essential as without it we will not be able to
contact you and answer your query., comments or whatever it is that you
have chosen to contact us about.
The following three items of information (title, First Name and Last
Name) are all optional. Therefore, if you wish to remain anonymous for
the purpose of the communication, that is totally acceptable to us as
we appreciate your desire to remain anonymous due to the sensitive
nature of this rather tragic situation. We desire to protect your
privacy at all times.
The country you live in is essential as it helps us to determine how an
answer may be give as we are totally aware of the cultural differences
that apply to this world wide problem of abuse.
The type of abuse you are the victim of (or perpetrator of) is
important so that we can also help when we commuicate with you.
Title
Title
Dr. Miss Mr. Mrs. Ms. Pastor Professor Rev. Other
Other
First Name
Last Name
Country
This helps us to know where you come from so that we may apply cultural
factors.
If your country is not listed, please write in the second box.
Country
AUSTRALIA AFGANISTAN ALBANIA ALGERIA AMERICAN SAMOA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA
& BARBUDA ARGENTINA ARMENIA ARUBA AUSTRIA AZERBAIJAN BAHAMAS BAHRAIN BANGLADESH BARBADOS BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA-HERZEGOVINA
BOTSWANA BOUVET ISLAND BRAZIL BRITISH
INDIAN OCEAN TERRITORIES BRUNEI
DARUSSALAM BULGARIA BURKINA FASO BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL
AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND COCOS
(KEELING) ISLANDS COLOMBIA COMOROS CONGO COOK ISLANDS COSTA RICA COTE D'IVOIRE CROATIA CUBA CYPRUS CZECH REPUBLIC DEMOCRATIC
REPUBLIC OF CONGO DEMOCRATIC YEMEN DEM.
PEOPLES REP. OF KOREA DENMARK DJIBOUTI DOMINICA DOMINICAN
REPUBLIC DRONNING MAUD
ISLAND EAST TIMOR ECUADOR EGYPT EL SALVADOR ENGLAND EQUATORIAL
GUINEA ERITREA ESTONIA ETHIOPIA FALKLAND ISLANDS FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH
SOUTHERN TERRITORRIES GABON GAMBIA GEORGIA GERMANY GHANA GIBRALTAR GREECE GREENLAND GRENADA GRENADINES GUADALOUPE GUAM GUATEMALA GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND HONDURAS HONG KONG HUNGARY HUTT RIVER
PROVINCE ICELAND INDIA INDONESIA IRAN IRAQ IRELAND ISRAEL ITALY JAMAICA JAN MAYEN ISLAND JAPAN JOHNSTON ISLAND JORDAN KAZAKHSTAN KENYA KIRIBATI KUWAIT KYRGYZSTAN LAOS LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MALVINAS MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MCDONALD ISLAND MEXICO MICRONESIA MIDWAY ISLANDS MOLDOVA MONACO MONGOLIA MONTSERRAT MOROCCO MOZAMBIQUE MYANMAR NAMIBIA NAURU NEPAL NETHERLANDS NETHERLANDS
ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN IRELAND NORTHERN
MARIANA ISLANDS NORWAY OMAN PAKISTAN PALAU PANAMA PAPUA NEW GUINEA PARAGUAY PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL PUERTO RICO QATAR REPUBLIC OF
KOREA REUNION ROMANIA RUSSIAN
FEDERATION RWANDA SAMOA SAN MARINO SAO TOME AND
PRINCIPE SAUDI ARABIA SCOTLAND SENEGAL SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH GEORGIA SOUTH
SANDWICH ISLANDS SPAIN SRI LANKA ST. HELENA ST. KITTS AND
NEVIS ST. LUCIA ST. PIERRE
ET MIQUELON ST. VINCENT SUDAN SURINAME SVALBARD ISLAND SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA THAILAND TOGO TOKELAU TONGA TRINIDAD AND
TOBAGO TUNISIA TURKEY TURKMENISTAN TURKS AND
CALCOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB
EMIRATES UNITED KINGDOM URUGUAY USA UZBEKISTAN VANUATU VATICAN CITY
STATE VENEZUELA VIETNAM VIRGIN
ISLANDS, BRITISH VIRGIN
ISLANDS, U.S. WAKE ISLAND WALES WALLIS
AND FUTUNA ISLANDS WESTERN SAHARA YEMEN ARAB
REPUBLIC YUGOSLAVIA ZAMBIA ZIMBABWE
Other
Sex (Male or Female)
Male Female
Abused As Child (Yes or No)
Abused As Adult (Yes or No)
Main Type Of Abuse
This helps us to know your main type of abuse.
If your abuse is not listed or you have additional abuses that apply,
please write in the second box.
Type
of Abuse
Sexual Physical Emotional Mental Verbal Financial Social
Deprivation Spiritual Spatial Other (Please us space
below)
The Comments
This things you
want us to know about your
specific problem. For many people, just being able to talk to someone,
especially if it is anonymous, can help immensly. Tell us just the
basic facts and feelings you have related to this problem