Name: Date:

1. Have you ever felt harassed, threatened, or stalked through technology (e.g., phone, text, email, social media)? Yes No 2. Has anyone tried to access your personal devices or online accounts without your consent? Yes No 3. Have you received unwanted or threatening messages, calls, or images online? Yes No 4. Has anyone tracked your location using technology or GPS without your knowledge? Yes No 5. Do you feel unsafe due to another person’s use of technology toward you? Yes No

Please describe any other concerns or experiences with technology-facilitated abuse:

Would you like help or more information about protecting your privacy and safety online? Yes No