Ordering Information

To order a free copy of the Prevention of Post-Sexual Assault and Stress DVD and brochure, please fill out the form below. A training manual as well as additional copies of the brochure are available in the download section of the website.

1. What is your professional affiliation?

Check all that apply«

Rape crisis staff or advocate

Nurse/Nurse examiner

M.D./Physican Examiner

Social worker

Psychologist

Psychiatrist

Mental health counselor

Researcher

Criminal justice personnel

Other

If you answered "other" please specify.

2. In what type of setting(s) do you work with female sexual assault victims?

Check all that apply«

Medical Exam Facility

Rape Crisis Center

Child Advocacy Center (CAC)

Other

Not Applicable

If you answered "other" please specify.

3. What is the age range of the people you work with?

Check all that apply.«

Children: 6-11 years

Younger adolescents 12-14 years

Older adolescents 15-17 years

Adults 18 years+

Not Applicable

4. What is the ethnicity of the people you most commonly serve?

Check all that apply.«

African American

Caucasian

Hispanic/Latino

Asian

Native American

Other

If you answered "other" please specify.

5. What percentage of the people you most commonnly serve speaks Spanish as their primary language?

Spanish%«

If you work with large numbers of other non-English speaking groups, please specify which languages they speak:

6. How do you think you might use this video?

Check all that apply.«

showing video to sexual assault victims in medical center

showing relevant parts of the video to sexual assault victims in a non-medical setting

showing video to train staff or volunteers who work with victims

for research purposes

not sure

7. How did you hear about the video or other materials? Please be as specific as possible (e.g. list the individual or agency that contacted or told you about the materials):

.«

Mailing Address and Contact Information

Name«

Institution«

Address«

City«

State«

Zip Code«

Country«

Email:«

Fields marked with "«" are required.

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