Sexual Abuse Confidential Survivor Questionnaire

If you or someone you love has experienced sexual abuse by an institution, we’re here to help. Please complete this secure form so one of our trauma-informed legal professionals can follow up with you confidentially. You may skip any question that feels too difficult right now.

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Contact Information

Full Name

Preferred Name (if different)

Phone

Email

Mailing Address (optional)

Address Line 1

Address Line 2

City

State

Zip Code

About the Abuse

Are you completing this form for yourself or someone else?

Myself
My child
Another loved one

How old was the victim when the abuse began?

Approximate year(s) or age range during which the abuse occurred?

Who was the abuser? (Job title or relationship to you, if known):

Was the abuser employed or affiliated with a specific institution? If so, which one(s)?

Were there other individuals who may have witnessed, known about, or been impacted by the abuse?

Yes
No
Unsure

Please explain if you can

Has the abuse been reported to authorities or the institution?

Yes
No
Unsure

Did the abuse result in any of the following (Check all that apply)

Legal & Support Information

Have you ever spoken to a lawyer about this abuse before?

Yes
No

Are you currently in therapy or working with a counselor or advocate?

Yes
No

Would you like us to connect you with a trauma-informed therapist or advocate?

Yes
No

safe you Layout

Would you be willing to speak confidentially with one of our attorneys to explore your legal rights and options?

Yes
No
Not Sure

Is there anything else you would like us to know right now?

Your Information Is Safe With Us

All answers are confidential. Submitting this form does not obligate you to take legal action. It is simply the first step in helping us understand how to support you.

If you prefer to speak directly with a team member, call us at 702.903.0800 for a free, private consultation.