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What is your age?
 
18-24
 
25-30
 
31-35
 
36+
 
Other
 
 
 
 
Marital Status?
 
Married
 
Single
 
Divorced
 
Seperated
 
Other
 
 
 
 
If Married, How long?
 
Less than One year
 
1 year+
 
5 years+
 
10 years +
 
 
 
How many children do you have?
 
0-1
 
2-5
 
5+
 
No Children
 
 
 
How old were you when you first became a vicitm domestic violence?
 
0-18
 
18-24
 
25-35
 
36+
 
 
 
After leaving the relationship, which services were most helpful to you?
 
Hotlines
 
Shelters
 
Long term counseling
 
short term counseling
 
Other
 
 
 
 
What do you consider to be your ethnicity?
 
 
 
 
What is your Occupation?
 
 
 
 
Religious Preference
 
Protestant
 
Catholic
 
Jewish
 
Muslim
 
Hindu
 
None
 
Other(please explain)
 
 
 
what is the highest grade/level of school completed?
 
8th grade or less
 
Some high school, but did not graduate
 
High school diploma or GED
 
Some college or Associate degree
 
4-year college
 
4+year college