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SHE WRITES WOMAN (SWW) AND WOMEN AT RISK INTERNATIONAL FOUNDATION (WARIF) CALL FOR VIRTUAL SUPPORT GROUP
All information provided is highly confidential and will be treated as such except adequately expressed.
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SWW in partnership with WARIF are using their 24/7 crisis counseling helpline as a first point of contact to ensure that survivors of gender based violence as well as those living with mental health conditions as a result of this global pandemic get access to a confidential service providing them with psychosocial support and counseling to reduce the risk of escalation during this covid-19 crisis.
Phone Number
Your answer
What is your name?
Your answer
What's your preferred way of reaching you?
Phone number
Email
Are you male or female?
Choose
Female
Male
What's the highest level of education you've attained?
Choose
Primary school
Secondary school leaving certificate
OND
B.Sc / HND
M.Sc
Diploma
Other
To understand your socioeconomic status, please choose your salary/monthly income range.
Choose
N1,000 - N10,000
N10,000 - N20,000
N20,000 - N50,000
N50,000 and above
Please indicate what best describes your locality.
Choose
Urban area (city)
Rural area (village)
What's your location?
Please include the state you currently reside
Your answer
Kindly indicate your age range
Choose
Less than 20 years old
20 - 25 years old
26 - 30 years old
31 - 35 years old
36 - 40 years old
40 years and above
How did you hear about the virtual support goup?
Choose
Social media
Through a friend
Traditional media (Radio, TV, or newspaper).
Other
Have you experienced any form of Gender Based Violence in the last 3 months?
Yes
No
Clear selection
Which of these forms of Gender Based Violence have you experienced within the last 3 months?
Sexual Harrasment
Rape
Emotional Abuse
Physical Abuse
Other:
Who is the abuser?
Stranger
Sexual partner
Friends and associates
Family member
Other:
How recent was the last abuse?
Less than 1 week
Between 1-2 weeks
Over 3 weeks
Over a month
Clear selection
Where did you seek help?
Choose
I reported at the police station
I went to the hospital for care
I reported to an NGO
I told a family member/neighbour/associate
I have not sought help
Has this experience impacted on your mental health and your daily functioning?
Yes
No
Maybe
Clear selection
Have you ever sought mental health support in the past?
Yes
No
Do you know or think that you live with a mental health condition, diagnosed or undiagnosed?
Yes
No
Maybe
If yes, kindly indicate the mental health condition here.
Your answer
Have you taken any medication to manage your mental health condition?
Yes
No
Has your mental health impacted your productivity in the last 3 month?
Yes
No
Maybe
How beneficial do you think a twice a month virtual support group will be to your mental health, on a scale of 1 - 3?
Choose
Extremely beneficial
Benefical
Not beneficial at all
How beneficial do you think a one-on-one virtual counseling will be to your mental health, on a scale of 1 - 3?
Choose
Extremely beneficial
Beneficial
Not beneficial at all
Has your mental health impacted your relationship (with family, friends, colleagues, partners etc) in the last 3 months?
Yes
No
Maybe
On a scale of 1 - 5, how mentally healthy do you think you are? 1 as lowest and 5 as highest?
1
2
3
4
5
Clear selection
Will you be willing to share your story anonymously?
Choose
Yes
No
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