Attention:

• This is an extensive form that takes time to complete. Feel free to submit a partially filled-out form if that works best for you.
• Be aware. In case of browser or transmission problems you may have to retype all information. We therefore suggest filling out the down-loadable Case Evaluation Form (PDF) or Word Format (doc) form. You can either email it as an attachment or use it to complete the on-line form. Right-click on either link and choose Save as…. Save the document to a place where you can easily find it.

Filling out this form will send the information directly to Steve Hassan. Please note that Steve will read your case evaluation form and offers a forty minute phone consultation for $100. All information is strictly confidential and will be handled as such.

Once you have sent the form to us, please call within two business days to set up your initial phone appointment.

Comments or questions are welcome.
*(denotes required field)

First Name*
Last Name*
Email*
Email Again
PERSONAL INFORMATION
Age
Sex	Male    Feale
Address	CityStateZip
Phone
Relationship to Cult Member
Who Referred you?
Name of Cult Member
HISTORY OF CULT INVOLVEMENT
Name of Group
Date Recruited
Where?
1) Briefly describe the chronology of events. Include details such as names of significant cult members and leaders; length of time from initial contact to full commitment; what jobs individual has had in group (as well as what location); what kind of communication individual has had with family and friends since joining. Please be as complete as possible!
2) What are the reasons given by individual why he/she has joined this group?
3) Has the individual ever expressed any doubts or difficulties as a member to anyone?
INDIVIDUAL'S FAMILY BACKGROUND
Father's Name Occupation
Mother's Name Occupation
Marital Status	Unknown Married Divorced Single
4) Which person has been closest to the cult member?
5) Describe the pre-cult family environment. Detail the significant relationships or lack of relationships. Describe the kind of communication patterns within the family. Have there been any fights or estrangements that have had an impact on family members? Have there been any significant changes? Has alcoholism/ drug use/ violence/ sexual abuse/ adoption affected any member of family? Please describe the family atmosphere as completely and accurately as possible.
6) Describe any other significant relationships. Include details about best friends; boy/girl friends; and any other close relatives. Describe any patterns of behavior observed.
7) Who is/is not willing to help? If anyone is unwilling to help, why?
INDIVIDUAL'S BACKGROUND
8) Educational background and interests:
9) Special hobbies and talents:
10) Religious background (and history of religious involvement):
11) Employment experience (include what jobs, where, how long and reason for leaving):
12) Previous career goals and aspirations:
13) Describe the person's physical health (history of medical problems):
14) Has there been any prior drug use (include which drugs, degree of use and treatment):
15) Describe the person's social, emotional and psychological well being (include any history of previous problems, i.e. death of relative or friend, sexual/emotional abuse etc.). This question should be answered by as many members of the family as possible.
16) Describe the individual's activities and state of mind just prior to joining. Please use as much detail as possible.
COURSE OF ACTIONS
17) Describe how each family member has reacted to the cult involvement. Include any details on the kinds of interactions with the cult member as well as the frequency. Please detail.
18) Describe what action you have taken until now. Include the names of any books or professionals (ex-members too) that you have contacted. If you have attempted an unsuccessful intervention, make sure to attach additional paper and describe fully.
19) Describe your plans for the future:
20) Are there any resources or limitations that we should know about? Please detail if there are large financial resources (property, bank accounts, trust funds) that the cult could be after or large debts, criminal charges or other liabilities to cult membership.
21) Is there anything else that we should know?
Security	(Please input 3 black symbols only)