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APPENDIX A
Measures of Community and Professional Services
SUPPORT GROUP SURVEY
I. This section asks general questions about you.
1. Today’s Date:________________________
2. Your Birthdate:________________________
3. Race/Ethnicity:
☐ Caucasian (white)
☐ African-American
☐ Asian, Pacific Islander
☐ Native American (American Indian)
☐ Other (please specify)________________________
Are you Hispanic/Latino? ☐ Yes ☐ No
4. Marital Status:
☐ Single
☐ Married
☐ Living with partner
5. Education Completed:
☐ Grades 0–8
☐ Grades 9–11
☐ High school graduate or equivalent
☐ Some college
☐ College graduate
☐ Post college
6. Employment status:
☐ Full time
☐ Part time
☐ Full time homemaker
☐ Student
7. If employed, what is your occupation or job? ________________________
8. If unemployed, would you like to be employed?
☐ Yes ☐ No
9. If “Yes”, do you think you have the skills to get a job right now?
☐ Yes ☐ No
10. Estimated household annual income: ________________________
11. Number of children: ________________________
12. Do your children live primarily with you?
☐ Yes ☐ No
13. Do you have health insurance?
☐ Yes ☐ No
14. Are you still living with your abusive partner?
☐ Yes ☐ No
15. If “No”, how long have you been separated from your abusive partner? ________________________
16. How long have you been in (were you in) this abusive relationship? ________________________
17. Approximately how many times did you leave or make an attempt to leave this abusive relationship? ____________ times
18. Approximately how many abusive partners have you had? ____________ abusive partners
II. This section contains questions about your use of different types of community services.
Physicians
19. Do you have a prima...
