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What is your current age?
 
18-25 years
 
26-35 years
 
36-45 years
 
46+ years
 
 
 
Are you
 
Single
 
In a committed relationship
 
Engaged
 
Married
 
Separated
 
Divorced
 
Widowed
 
 
 
How old were you when you were sexually abused as a child or when the abuse began
 
Under the age of 5 years
 
6-10 years
 
11-15 years
 
16-18 years
 
 
 
How many times did the abuse occur?
 
Once
 
Between 2-5 times
 
Between 6-10 times
 
Over 10 times
 
I can't remember
 
 
 
The person who sexually abused you was
 
Stranger
 
Babysitter
 
Neighbor
 
Family Friend
 
Teacher
 
Mother
 
Father
 
Grandmother
 
Grandfather
 
Stepmother
 
Stepfather
 
Brother
 
Sister
 
Aunt
 
Uncle
 
Cousin
 
Someone else
 
 
 
How old were you when the sexual abuse stopped?
 
Under the age of 5
 
6-10 years
 
11-15 years
 
16-18 years
 
 
 
Did you ever talk to anyone about the abuse as a child?
 
Yes, I was helped
 
Yes, but I was not believed
 
Yes, but nothing changed
 
No I did not tell anyone
 
 
 
Do you still keep in contact with the person who sexually abused you as a child?
 
Yes
 
No
 
 
 
Do you believe that you have difficulties trusting others?
 
Yes
 
No
 
I don't know
 
 
 
Have you ever cheated on your significant other?
 
Yes
 
No
 
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