Free Peer Support Questionnaire

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SCREENSHOT OR MAKE NOTE OF THESE STEPS!!!
STEP 1: Complete this Form
STEP 2: Send an email to nikki@survivorledmovement.com
(Copy/Paste Subject Line: PLEASE SEND APPOINTMENT CALENDAR)
STEP 3: Choose a meeting date from Nikki's Calendar
(I will send it as a response to your email above)
STEP 4: Show up!
All information shared will be kept confidential.

Email *

Name (Alias is ok): *

Phone number, general availability, time zone
(example: 555-555-5555 after 4pm EST): *

I understand that Survivor Led Movement provides Free Peer Support through the mutual-aid-supported Peaceful Life Project. Peer Support Providers are Survivors of IPV with lived experience as abolitionists who have divested from Family Policing. Peer Support Providers have received extensive training as subject matter experts with lived experience. We do not partner with the police or any adjacent agencies in any way nor do we provide legal or medical advice.
By selecting "Yes," I acknowledge that I understand all of the above: *

YES

I have questions

Survivorship Safety Demographics
(check all that apply): *

I live with my abuser.

I share child custody with my abuser.

I live separately from my abuser but still see or communicate with them regularly.

I live separately from my abuser and practice grey rock.

I experience stalking, threats, and fear for my safety.

I've been granted an order of protection.

I am involved with social services that I find helpful.

I am involved with social services that are intrusive and detrimental to my (and my children's) well-being.

I feel free to speak openly about my Survivorship.

I fear repercussions for speaking openly about my Survivorship.

I would like to complete a Lethality Assessment.

I would not like to complete a Lethality Assessment.

I have completed a Lethality Assessment.

Required

Survivorship Security Demographics
(check all that apply): *

I cannot afford my own housing and live with my abuser.

I cannot afford my own housing and live with family, friends, roommates, or in a temporary shelter.

I have a job, but the pay does not meet all of my basic needs.

I am in considerable debt and cannot borrow any survival funds.

I am able to afford my own housing and meet basic needs, but am overworked and in debt.

I have a job that allows me to afford a modest lifestyle and maintain a savings account.

I am able to afford the lifestyle of my choice and contribute to causes that I care about.

Required

Survivorship Well-being Demographics
(check all that apply): *

I sleep well most nights and wake feeling refreshed.

I struggle with sleep.

I eat food that is right for me, at the right time, in the right amount and I digest it well.

I experience inconsistent appetite, bloating, cramps, unintended weight gain/loss, irregular elimination patterns (constipation, diarrhea, or both).

I move my body regularly.

I rarely move my body.

I am able to concentrate on tasks, think creatively, identify opportunities, and problem solve.

I am easily distracted, feel too overwhelmed or frustrated to problem-solve, and have lost interest in creative projects.

Survivorship is really difficult but I have hope that we can change cultural violence.

Survivorship is really difficult and I don't see how we can change cultural violence.

Required

My experience with Yoga is mostly like: *

I've never practiced yoga.

I've followed some Youtube videos or online classes.

I've taken some in-person studio classes.

I've completed some teacher training.

My daily practice is well established (or I would like it to be).

I've had negative experiences and am uninterested in learning more.

Required

My experience with Ayurveda is mostly like: *

I have no idea what it is.

I've read about it.

I've taken a basic workshop.

I've completed some teacher training.

My daily practice is well established (or I would like it to be).

I've had negative experiences and am uninterested in learning more.

Required

Which of your current unmet needs should be prioritized for our meeting discussion?
Examples:
1. Survivor-abolitionist strategies to avoid/disengage from financial/legal abuse.
2. Survivor-specific self-care practices to support well-being.
3. Survivor-abolitionist organizing practices.
4. Skilled empathy, reflection, and co-regulation practice.
5. Something else- please be as specific as possible to maximize our time together. In some cases, given enough information, we may be able to provide an appropriate referral.

*

What else do you need me (Nikki) to understand about your Survivorship? *

How did you hear about The Peaceful Life Project?
*

Now that I have completed this form, I am sending an email to nikki@survivorledmovement.com.
I am using Subject:
PLEASE SEND APPOINTMENT CALENDAR. *

Send me a copy of my responses.

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