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PARTNER RAPE
IS

REAL RAPE


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SEXUAL ASSAULT SERVICES DATABASE INPUT FORM

Please use the form below to put information about your service into the Sexual Assault 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(availabe 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.

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

Your service recognises special considerations for IPSV Survivors? (Check for Yes)
Service Name:
Service Website Address?:
Country:
State/County/Region:
City:
E-mail Contact (if appropriate):
Phone Contact incl. area code (if appropriate):
Hours of Service Availability (Crisis Line, other; if different services/hours, start new line for each).
Is there a Free Crisis Number?
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)?
Can a Survivor still living with the partner who sexually assaulted her access your service (check for yes, leave unchecked for no)?
What types and modes of counselling does your service offer i.e. Crisis, short-term, long-term, telephone, face-to-face, email, online chat?
Counselling Approaches Used i.e. CBT, Psychodynamic, Feminist-based, Combination (Please elaborate)
Other Services Offered i.e
Police advocacy, Support groups suitable for IPSV survivors, referrals to other community resources for abused women (Please elaborate):
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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