New Member Survey

This is a sample New Member Survey that can be used to evaluate requests from people to join a support group. Please feel free to use it, and be sure to let us know your suggestions for how to improve it!

Every member in the Support for Partners of Survivors group must complete this New Member Survey. It serves a few purposes. We need to feel confident that new members are in a genuine partner-relationship with a survivor of sexual abuse. We also need to determine if new members will fit into the group, or if there are multiple groups then which one has the best fit. This survey will be reviewed by the group's Meeting Leader and/or Coordinator, who will take it to the group for review, discussion and approval. One of them will contact you after that to inform you if you've been accepted into the group and provide you with information on the group's meeting schedule and location. If you are not accepted into the group they will explain the basis for that decision. Your information will remain confidential within the group.

1.Your name:

2.Your partner's name:

3.Please provide us with information on how to contact you – a phone number is required but you can provide more than that if you have other preferences:

4.How long have you and your partner been together?

5.What is the status of your relationship – married, living together, separated, divorced?

6.Do you have children? If so, how many and how old are they?

7.Are you involved in any legal proceedings? If so, what are they?

8.Have you ever been in a support group before? What was it, and what was it like for you?

9.What are three goals you have for your participation in the Support for Partners of Survivors group?

10.Are you comfortable with a mixed-gender group, or would you prefer a single-gender group?

11.Are you comfortable in a group that includes both gay and straight partners?

12.Are you currently seeing a therapist or counselor? If so, for how long?

13.Is your partner getting therapy or counseling? If so, for how long?

14.Are you currently managing any major life events or stress? What are they?

15.Have you ever experienced sexual abuse?

16.What is your worst fear about your participation in this group?

17.What is your greatest hope for your participation in this group?

18.Are you able to attend biweekly group meetings? Are there any special circumstances that may need to be considered, such as child-care, evenings-only, weekends-only?

19.Have you read the groups' charter, and if so do you agree to conduct yourself in accordance to it?

20.Please use this space to tell us anything else you may feel needs to be mentioned.

Your signature:

Date: