W Films -- Living A Secret - Interview Application

DISCLAIMER -- Filling out this questionnaire does not guarantee your involvement in the documentary. All information submitted to W Films and LAS Productions via the forms below is confidential and record keeping adheres to all privacy policies and laws.

PERSONAL INFORMATION

Full Name:

Contact Email:

Phone Number:

Date of Birth:

Occupation:

City / State:

Relationship Type:

Do you have children?
Yes No
If yes, how many?
1 2 3+

USE OF IMAGES AND LIKENESS

Are you willing to use your real name?
Yes No
Are you willing to show your face on camera?
Yes No
Are you willing to use your real voice?
Yes No
Do you have still photos you can contribute?
Yes No
Are you willing to sign a 'Release Form?'
Yes No

DETAILS OF YOUR STORY

What type(s) of abuse did you experience? (Check ALL that Apply)
Sexual Incestual Rape Physical Emotional/Verbal
At what age did the abuse begin?

At what age did the abuse end?

Who else knows about the abuse?

Was the abuse (legally) reported?
Yes No
Was your abuser investigated / sentenced?
Yes No
Did your abuser abuse anyone else?
Yes No Suspected
Did you confront your abuser?
Yes No
If no, would you be willing to?
Yes No
If willing, what do you hope to gain from it?

What types of treatment have you sought?

Do you feel the treatment(s) worked?
Yes No
Do you have any self destructive behaviors?
Yes No
If yes, what are they?

What are your coping methods?

How does the abuse affect your relationship(s)?

Is your 'significant other' willing to contribute to the project for support?
Yes No Not in a relationship
Briefly, tell us your story in your words:

Terms of Use / Digital Signature

By digitally signing this submission with my full legal name in the text box below, I authorize W Films and/or LAS Productions to contact me regarding my story and my submission for inclusion and use in the documentary project, tentatively titled, "Living A Secret." I also attest that the above information is factual without embellishment.