Confidential Intake Questionnaire

Men who have experienced sexual victimization frequently face difficulties in disclosing their experiences due to the influence of erroneous male stereotypes constructed throughout history to define the characteristics of a "Real" man. Society often places a certain admiration bestowed upon men who demonstrate strength and stoicism, refraining from expressing grievances about the harm inflicted upon them.

Remaining silent about abuse impedes your path to genuine healing and inadvertently shields the perpetrator and those in positions of authority who failed to provide protection.

If you have been a victim of sexual abuse involving individuals associated with Chi Alpha Ministries, we strongly encourage you to come forward and confidentially fill out this questionnaire. This step could open up legal avenues for seeking justice and ensuring accountability to everyone involved.

Please answer these questions to the best of your ability:

A. Personal Background Information

Name

First Name

Last Name

Email

Phone

(###)

###

####

Your date of birth?

MM

DD

YYYY

Where do you currently live?

B. Description of Abuse

1. Do you believe that you were sexually victimized by someone associated with Chi Alpha Campus Ministries?

Yes

No

2. Please provide the approximate year/s and location/s (state) that you were sexually victimized by the person associated with Chi Alpha Ministries: Year/s and State/s:

3. Please provide the name and position of person(s) who sexually victimized you:

4. What college or university was the person who sexually victimized you working with in his association with Chi Alpha Ministries?

5. Please provide a brief confidential summary of the sexual misconduct perpetrated against you by the individual associated with Chi Alpha Ministries?

Consult with an Attorney

Confidential Intake Questionnaire