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You deserve to be whole – our God would have it no other way.
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Name
*
Do you want your name revealed publicly?
*
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Phone or Email Address:
*
Current Location (City, Country):
*
Date Of Incident:
*
Location Of Incident (City, Country):
*
Nature of Incident:
*
Assault
Harrassment
Intimidation
Rape
Threat
What Happened?
*
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Action You Took:
How has it affected you?
Why are you speaking now?
What would you like to do?
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Name of Abuser :
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