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PARTNER RAPE
IS

REAL RAPE


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COUNSELLING SERVICES DATABASE INPUT FORM

Please use the form below to put information about your service into the Counselling Services Database.
Your information will appear when you have submitted it and filled in the CAPTCHA Spam-preventer.
Please note that you need to check the box that asks if you understand considerations about IPSV for your type of service (available here), but you may leave any other field blank if it is not relevant.
However, please fill in as much as you can to ensure that survivors have sufficient information about your service.

In asking about your qualifications, this is because survivors often need these details. Just as importantly though, while I believe that some level of qualification is essential when working with traumatized people, the level of qualification often matters less than the counsellor's ability to work well with sexual assault and domestic violence clients.

Thank you so very much for your assistance with this project.

You recognise special considerations for IPSV Survivors?
(Check for Yes)
Your Name or Business Name:
Your Qualifications (if more than one, start a new line for each)?:
Any fields of specialization (if more than one, start new line for each)
Website Address?:
Country:
State/County/Region:
City:
E-mail Contact (if appropriate):
Phone Contact incl. area code (if appropriate):
Hours of Service Availability (If different services/hours, start new line for each).
Cost of Services (please choose):
If costed, do you wish to elaborate
(for example, can a client get reduced costs
if she has a referral)?
Counselling Approaches Used
i.e. CBT, Psychodynamic,
Feminist-based, Combination (Please elaborate)
What types and modes of counselling does your service offer
i.e. Crisis, short-term, long-term, telephone, face-to-face, email, online chat?
You are comfortable with sexual assault/domestic violence and pursuant issues,
and can empathically respond to these issues (Check for Yes)?
Do you work with issues that could be advantageous with an IPSV survivor
i.e.PTSD, Panic/Anxiety, Depression, Sexuality (please elaborate)?
Other Services Offered i.e Medical advocacy, Psychological reports,
referrals to other community resources for abused women (Please elaborate):
Your Gender: Male Female
Do you have a message of outreach for
IPSV survivors who may seek out your service?
Other information about your service you think is necessary?


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