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Family Case Evaluation Form

 

Information for family and friends with a loved one under undue influence

 

This questionnaire is confidential. This form is a tool to help us help you. Some people find this form overwhelming. If you have difficulty completing this task, do the best you can. If appropriate, ask other family members and/or friends for their input. It is very important to have all relevant personal information that may have a bearing on the case. We ask that you limit it to 10 pages. Including photos will help us serve you better, but please know it is optional.

Date
Your Name* First:Last:
Email*
Street1
Street2
City/State/Zip CityStateZip
Phone
Your relationship
to involved individual
Who Referred
you?
Name of
Cult Member
Age
Sex Male    Female
HISTORY OF CULT INVOLVEMENT
Name of Group
Name of Leader
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
Siblings Name, Age, Sex, Occupation & Location
4) Which person (outside of the cult) 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?
Thank you for completing the confidential case evaluation. Please also consider sending a photo of yourself, your loved one or family, but it is optional. We encourage you to call the office to talk about next steps. We can answer any questions you have at that time as well. If you prefer to print and fax or mail the case evaluation, our contact info is below:

Freedom of Mind Resource Center, Inc.
716 Beacon Street #590443
Newton, MA 02459
Phone (617) 396-4638
Fax (617) 628-8153
Email center@freedomofmind.com
Web: http://www.freedomofmind.com

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