Gift From Within Pen Pal Questionnaire
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Welcome to Gift From Within Email Support Pals. This is a list for women who suffer or who have suffered from Post-Traumatic Stress Disorder (PTSD). If you would like to communicate with other survivors we suggest you complete the form below. The purpose of this service is to give survivors the opportunity to connect emotionally with others about what they are feeling and experiencing. This support system also gives survivors the unique opportunity to help others in need. This service is not meant to be a substitute for any kind of professional help, therapy, or crisis services.

For Mental Health Professionals: If you are interested in finding a peer support pal also in the health profession please call Joyce @ 207-236-8858.

For Men: If you've experienced the following.....sexual assault, physical abuse, trauma from being robbed, beaten, REMEMBER....YOU ARE NOT ALONE....the following sites could be most helpful for you: For Men Only

All names are kept strictly confidential. After receiving our email guidelines please contact Joyce at 207 236-8858 EST for a phone screening.

At present, the Support Pal Network is not accepting people who are currently incarcerated and/or in psychiatric hospitals.

I understand that by signing this release form that:

- GIFT FROM WITHIN will assist me in finding a phone/pen/email support pal. GFW may contact me by either email or phone.
- GIFT FROM WITHIN will create a short biography based on my completed form that will be shared with members only.
- GIFT FROM WITHIN will keep my name and address confidential within the support pal network.
- GIFT FROM WITHIN will send me names and addresses after I return the questionnaire and complete a telephone screening with Joyce Boaz.
- GIFT FROM WITHIN may from time to time send me questionnaires that will be computerized and only used for scientific studies on PTSD. I hereby authorize the use of such questionnaires that I may sign for such purposes.

As a GFW Phone-Pen-Email Support Pal, I agree to the following:

1. All names will be kept confidential;
2. That I will not hold GFW or its Board Members responsible or liable in the event that the relationship does not work, no matter the reason. I understand there are no guarantees and some risk is involved.
3. I understand that a support pal could say something during our correspondence or communications that could be triggering and I need to be mindful of my own needs and limitations. I will also behave kindly and gentle towards others, remembering we are all in this together.

Please provide: Personal History: name, age, gender, traumatic experience, why you want this service. (Some of this info will be shared with members only).

Please print:




City___________________________________ State________


Why I want this service (include traumatic event)


Hobbies and/or things that I enjoy___________________________________________

How did you find us?_________________________________________________________


Language Preferences

(bilingual helpful)__________________________________

Phone______________________________________________ Email: ________________________

Your signature___________________________________________________________