PLC Group Screening

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PLC Group Screening

Email *

What is your name? *

Would you like to be added to PLC's email contact list? *

Yes

Required

Would you like to be added to PLC's WhatsApp Text Chat for Male Survivors? (Chat membership required to access our weekly LIVE Zoom podcast calls) *

Yes (Chat link will be emailed to you)

Other:

Required

What is your gender? *

Male

Female

Other:

What Phone Number will you be using for the WhatsApp Chat? (include your country code - US="1-"; if not joining the WhatApp ChatRoom, enter "N/A") *

What COUNTRY is this phone number assigned to? *

Are you currently a member of Husband Material (helping men find freedom from P0rn Addiction)? *

Yes

Required

What is your Husband Material User/Display Name? (ex: "John S" or "J S" or "John Smith") -- if NOT a member, enter "n/a"
*

History of inappropriate sexual contact/abuse/neglect (check all that apply)
*

1) Sexually abused by another person when I was under the age of 18

2) Sexually assaulted by another person when I was under the age of 18

3) Experienced sexual shame for any reason when I was under the age of 18

4) Felt sexually used for any reason when I was under the age of 18

5) Sexually Abused by another person when I was age 18 or older

6) Sexually Assaulted by another person when I was age 18 or older

7) Experienced sexual shame for any reason when I was age 18 or older

8) Felt sexually used for any reason when I was age 18 or older

9) I have never been abused or assaulted at any time at any age by another person but would still like to join (please also check "Other" below with an explanation)

10) I am not sure if I was ever abused or assaulted at any time at any age by another person, but i remember "Yucky Stuff" happening to me.

Other:

Required

As an adult (age 18 or older) have you ever sexually abused or assaulted a minor child (under age 18)?
*

Yes (please also select OTHER and EXPLAIN)

Other:

Required

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