Form Page Take me back Fill in the form Answer the following questions so that we can link you with your nearest service provider. Name How old are you? * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Are you a boy or a girl? * Boy Girl Which town do you live closest to? * Bloemfontein Cape Town Durban East London Grahamstown Johannesburg Kimberly Ladysmith Mafikeng Mthatha Nelspruit Oudtshoorn Pietermaritzburg Polokwane Port Elizabeth Pretoria Queenstown Rustenburg Soweto Springbok Tonga Upington Welkom Witbank Tell us about what has happened to you? * Someone bullied me Someone physically hurt me Someone raped me Someone sexually abused me Someone threatened to harm me When did this happen? * This week This month This year More than a year ago Tell us who you have told about this so far. * I told my sibling I told an adult not related to me I told an adult family member I told a friend I told the police I told a teacher I told no one Check that the details you entered above are correct, and then click SUBMIT.