Dating Violence Stories

1. What is today's date *This question is required.

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We will raffle off a prize (gift card worth $25) every 6 months for those respondents who share with us their true story of dating violence.

2. What is your age? This question requires a valid number format.

4. What is your sexual orientation?

5. What is your ethnicity/ethnic background?

6. Tell us your story. Use as much or as little detail as you wish. Your story will help us do a better job of informing research and prevention efforts. If we use any part of your story for publication we will change the names (if provided) to protect your anonymity.

8. If you would like to be entered into the raffle please enter your email address here: This question requires a valid email address.

Dating Violence Stories

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