Healthy Relationships Post-Survey

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* 1. What is your age category?

14 and under

15-20

21-24

25-34

35-44

45+

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* 2. What are 3 forms of abuse?

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* 3. If a person is high on drugs or intoxicated by alcohol can there be clear consent given?

Yes

No

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* 4. Is it appropriate for you partner to coerce you into sexual activity?

Yes

No

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* 5. What type of relationship is it if a partner repeatedly and/or intentionally isolates you from friends and family?

Healthy relationship

Unhealthy relationship

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* 6. Communication is important in a healthy relationship.

True

False

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* 7. How did you hear about Midtown Health Center?

Social media (Facebook, Twitter, Instagram, Snapchat)

T.V. or Radio

From friends or family

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* 8. What is 1 thing you learned today?

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* 9. If you would like to be entered into the drawing for a gift card, please leave your contact information below!

Name

Email Address

Phone Number