Online Contact Form: Helping Someone in Trouble Case Evaluation Form

Wish to help a family member or friend who is in a controlling group or relationship? This form asks for a lot of information as it will help us with our initial consultation.

BEFORE ENTERING ANY INFORMATION INTO THE ONLINE FORM, please type up your form responses into a document file to save for your reference. Scroll down to find the form questions to copy and paste into your document. Or download the PDF of the online form to see the questions. Fields marked with an asterisk * are required, please. Saving your information into your own document will ensure you have a copy of it in case of any technical issues with the online form.

Some clients prefer to give us the details orally.

Others prefer to email their information. To help protect your privacy, use ProtonMail – encrypted email to center@secure.freedomofmind.com. Before emailing your information, please format it using Times New Roman 12 pt font, spaces between paragraphs and 1 inch margins. You may send the information pasted into the body of the email or as an attached PDF. We do not accept other types of document files as attachments.

If you can give us as much detail as possible within 10 pages, please do so as it is considered part of the initial consultation. You may submit additional materials for review prior to the initial consult, such as investigative, medical or legal reports; copies of communications; and photos. Review of up to 10 pages of material, inclusive of the case evaluation form, is included. There is an additional charge to review over 10 pages.

During the initial consult, you and Steve will discuss your Case Evaluation Form and any other materials that you have submitted. Some people prefer to give more sensitive information directly to Steve during the consultation. Steve will answer your questions and provide recommendations for the next steps including strategies, intervention services, post-intervention recovery resources, and other resource and referral options.

Thank you,

Steven Hassan

Helping Someone in Trouble Case Evaluation Form

Fields marked with an * are required

Your Information

Name(Required)

First Last

Your Preferred Phone(Required)

Secondary Phone

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

How did you hear about us? (Did you get a referral from a person or group? see a blog? Please be specific.)(Required)

Group Information

Name of Controlling Individual or Group(Required)

Location of the Controlling Individual or Group(Required)

Names of Group Founder(s)

Current Leader(s)

Are there links to websites or other social media by this controlling entity? List them, please.

Are there lawsuits, blogs, articles, books, documentaries or websites critical to the group, please list here.

Have you spoken to any vetted (bone fide) former members of the group? Are they willing to help? Please list their name and contact information (with their permission, of course).

Person you are concerned about

Who are you concerned about?(Required)

First Last

When were they recruited into the group or relationship?

Where are they located now?

Your relationship to the person you are concerned about(Required)

Their Age(Required)

Their Gender

What were their previous hobbies, interests, and career goals?(Required)

What is their religious background?

Please describe their health (physical, mental, emotional, social).

List any therapists or other healing services they have used

List any helpful books, podcasts, websites, TV shows, movies, and documentaries

What are the reasons your loved one has given for became involved with the controlling group/individual?

Briefly describe the chronology of events within the high control group or relationship: Include details such as names of significant cult members and leaders; length of time from initial contact to full commitment; jobs or roles the individual has had in the group (as well as what location); what kind of communication the individual has had with family and friends since joining. Please be as complete as possible.

What doubts have they expressed, and to whom?

Please list and describe immediate family members’ names, age, sex, occupations and location.

Describe the family environment before they became involved in the controlling group or relationship.

Describe any other significant relationships. Include details about best friends; boy/girlfriends; and any other close relatives. Describe any patterns of behavior observed.

Who is willing to help (friends, family...)?

Who is not willing to help and why?

Which person (outside of the cult or controlling relationship) has been closest to the cult member?

What actions have you already taken to help this individual?

What are your current goals?

Is there anything else we should know?

Online Contact Form: Helping Someone in Trouble Case Evaluation Form

Your Information

Group Information

Person you are concerned about

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