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* 1. Name

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* 2. Pronouns

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* 3. Gender;

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* 4. Race/ethnicity;

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* 5. Contact info & preferred method of contact

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* 6. County/town;

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* 7. Age;

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* 8. Which support group are you wanting to join?

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* 9. Have you seen a therapist or counselor previously about sexual violence?

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* 10. What supports have you tried/utilized related to sexual violence? (ex; other support groups, therapy, talking to friends, meditation, writing etc)

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* 11. What, if any, accessibility needs do you have? (Physical, mental health, emotional, intellectual.)  For example, some participants want the facilitators to know that they are experiencing PTSD or that they have Bipolar.  We want to make sure we are supporting you in the best ways we can.

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* 12. How did you hear about our support groups?

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* 13. Have you been in a support group before? What was that experience like for you?

OCRCC Support Groups are a peer-support based model. This means there will be a combination of educational portions, activities, and peer sharing and support.  These groups are not clinical and are facilitated by trained OCRCC facilitators.

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* 14. What might you hope to learn during the support group, or what goals do you have for participating?  (some examples; connection, community, learn that I'm not alone, why does SA happen, healthy relationships etc)

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* 15. Part of the support group is sharing parts of your personal story and hearing about others.  While sharing is not required, we want to make sure you feel comfortable in sharing and listening to the stories of others.  How comfortable are you with sharing/listening to stories of trauma?

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* 16. In times of stress or feeling triggered/activated, what forms of support do you need from a facilitator?

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* 17. Logistical Questions; 
Do you have access to;

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* 18. Do you have any other specific needs to make the support group more accessible for you?

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* 19. What other questions do you have?

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