NAME: E-MAIL:

1] Please enter the choice that best describes your position at this time:

intern/under grad intern/grad student grad student post grad practicing therapist

supervisor other

2] I treat or am interested in treating:

primarily adults primarily children adults & children family groups

3] In terms of the objectives outlined in the Guidelines for Participation:

a] Do you feel you have a clearer understanding of childhood developmental stages as they relate to the child's cognitive abilities for comprehending sexual abuse?

yes, very much yes somewhat very little no, not at all

b] Do you feel you have a clearer understanding of childhood developmental stages as they relate to the child's linguistic abilities for describing sexual abuse?

yes, very much yes somewhat very little no, not at all

c] Do you feel your appreciation for the consequences (both real and perceived) surrounding the disclosure of sexual abuse, by a child to an adult, has increased?

yes, very much yes somewhat very little no, not at all

d] Were you able to hear the negative messages and experience the feelings of a sexually abused child?

yes, very much yes somewhat very little no, not at all

e] Were the varied scenarios that developed in your group of 3-4 people believable to you?

yes, very much yes somewhat very little no, not at all

f] Do you feel you have an increased appreciation for and understanding of childrens' reactions and coping mechanisms in response to trauma?

yes, very much yes somewhat very little no, not at all

g] Do you feel the puzzle board and removal of puzzle pieces is an effective medium for conveying a visual sense of the loss of self?

yes, very much yes somewhat very little no, not at all

h] Do you feel the puzzle board and removal of puzzle pieces is an effective childlike activity that enhances the overall feeling of regression experienced with this exercise?

yes, very much yes somewhat very little no, not at all

i] Was the age card you drew an effective reminder of what it is/was to be that age/sex child?

yes, very much yes somewhat very little no, not at all

4] The follow-up portion of this exercise was entirely directed by your facilitator. Topics-of-Discussion and Scenario Information Sheets are included as part of the program, but that does not mean your facilitator chose to use them. The Scenario Information Sheets are intended to be used only by interns. My facilitator used:

the Topics-of Discussion

the Scenario Information Sheets (interns only) Please indicate whether the following components of the Scenario Information Sheets were helpful as a way of introducing you to the realities of therapeutic practice?

a] Note as to the subjective appearance of the patient

yes somewhat no

b] Availability and extent of mental health coverage

yes somewhat no

c] Whom the patient is being referred by

yes somewhat no

d] Patient's perceived reason for referral

yes somewhat no

e] Patient's biographical description of childhood

yes somewhat no not sure

other (please describe)

 

5] "Demographics"

a] are you: female or male

b] for this exercise were you: female or male

c] What was the total number of people who participated in this exercise when you did?

3 4 5 6 7 8 9 10 11 12

d] At what age did you begin to be abused in this exercise?

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

6] At what point in your professional development do you feel this curriculum would be most useful?

undergraduate studies graduate studies during internship continuing education credits

7] Overall, I would rate this exercise as:

excellent good fair poor

8] Please fill-in the training institution and/or organization with which you are affiliated at this time. This information will be used only to verify the authenticity of your participation. Your response will be compared with the list of institutions and organizations who have the MESSAGE Program. If it does not match, we cannot use your responses. If MESSAGE was on loan from another organization, please indicate the names of both organizations.

Training institution and/or organization:

On loan from:

9] Please feel free to write any other comments or suggestion here. Questions will be answered.