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Ex-Member Case Evaluation Form

Information about services for ex-members

In addition to cult cases, we have been helping people involved in destructive one-on-one relationships, mini-cults and other unusual situations. All involve radical personality changes, often resulting in dropping out of school, work, alienation and loss of contact. Some involve covert uses of hypnosis and sexual abuse.

Please provide the following confidential background information before your first appointment via this secure form.

Filling out this form might take a while. You may decide to answer all of these questions in the form of an email while you are not online. Filling out this form will send the information directly to the Freedom of Mind Resource Center.   All information is strictly confidential and will be handled as such.

In case of browser or transmission problems you may have to retype all information.   We therefore suggest filling out the downloadable Case Evaluation Form (PDF) or Word Format (doc) form in order to email it as an attachment. Right-click on either link and choose Save as…. Save the document to a place where you can easily find it.

Feel free to call our office to verify this form's arrival and to make an appointment for a phone consultation, if desired.   Our office number is (617) 396-4638.  Please do not forget to include a photo of the ex-member. A photo of the entire family would also be helpful.

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

First Name*
Last Name*
Email*
PERSONAL INFORMATION
Age
Sex Male    Female
Street1
Street2
City/State/Zip CityStateZip
Phone
How did you find Freedom of Mind Resource Center?
HISTORY OF ABUSIVE CULT OR RELATIONSHIP INVOLVEMENT
Name(s) of Group
Leader's Name
Date Involved in Group
Where?
Briefly Describe Your Relevant Personal History:
Do you have any family or friends still involved? Who?
Do you still have contact or continue any practices you learned with group?
RECOVERY AND RESOURCES
Have you worked, or are you currently working with any other therapist or support group? Please give details.
Have you read any books about mind control issues? List the best ones:
Have you watched any good videos/television specials that were helpful to you?
List the issues/problems that you are dealing with. Some of most common are: 1. Extreme identity confusion 2. Dissociative states - "floating"(getting triggered back into cult mode) 3. Panic and anxiety attacks 4. Depression 5. Post-Traumatic Stress Disorder (PTSD.) 6. Psychosomatic symptoms (headaches, backaches, asthma, skin problems) 7. Problems with decision-making dependency 8. Retarded psychological development- loss of psychological power 9. Guilt 10. Fear 11. Sleep disorders/ nightmares 12. Eating disorders 13. Sexual problems / Sexuality Issues 14. Lack of trust / fear of intimacy and commitment - people/work 15. Harassment and threats 16. Grieving loss of friends, family 17. Spiritual "rape" of the soul.
Is there anything else that we should know?
9 + 4 =