1.	Gender
	Male  Female

2.	Age

3.	Country of Origin

4.	Is English your first language?
	YesNo

5.	Are you a torture survivor?
	Yes  No  I don't know

6.	In your professional capacity, do you provide direct service to torture surviors?
	YesNo

7.	In your professional capacity, do you have contact with torture survivors?
	YesNo

8.	Name of institution or agency (if applicable)

9.	Which best describes your background?
	Health professional Mental health professional Refugee health worker Social service provider Mutual assistance association provider Asylum lawyer Vocation rehabilitation specialist Student Other, please specify

10.	How did you find our Website?
	Search Engine (Google, Yahoo, Ask.com, etc) Referred by colleagues Referred by survivors Referred by legal agency Referred by health provider Other, please specify