Content Adaptation Request Form

Service Fee
There is a $25 USD service fee associated with these requests. Payment is not a guarantee of approval, and is intended to compensate for employee time needed to review requests. Requests will not be reviewed until payment is made. There is a link to follow at the end of the questionnaire.

Information about your request
Which wheel would you like to adapt?*
Title of your adaptation*
Were victims consulted throughout the process?*
- Yes
- No
Did victims approve the final draft of the adaptation?*
- Yes
- No
Intent and purpose*
Explain why you want to create this adaptation and what you will accomplish with it. Also explain why the original Power and Control Wheel does not achieve this purpose.
Victim's experience*
Explain how your adaptation reflects victim's lived experience.
Focus groups*
Describe the focus groups you used to create your adaptation; number of groups, how many people were in each group, demographics of each group, total number of people, how many times you met with each group.
Analyzation*
Explain the process you used to analyze the information you were given in the focus groups.

Uploads
Image of the wheel*
Provide a copy of the final draft of your proposed adaptation, including appropriate credits.
Max. file size: 25 MB.

Payment
Service Fee*
Price:
Credit Card
Card Details
Cardholder Name
Billing Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
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Service Fee