Online Contact Form: Healing and Recovery Case Evaluation Form

Wish to receive services to help yourself heal and recover from the effects of 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 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

Healing and Recovery Case Evaluation Form

Please check the issues you are currently dealing with. Feel free to use more than one check if it is a major issue.