Please note: We have created an abbreviated intake questionnaire to help us begin thinking about your potential case. Of course we will go into more detail with you directly, but this will help to start the dialogue. Also, we have found that by beginning the process it helps one to not feel so isolated and alone.
Please do not worry if you cannot answer all of the questions; just do the best you can.
1. Did the misconduct or malpractice occur in private therapy, group therapy, couples or marital counseling, or in a hospital setting? Did it occur in therapy session, or outside of therapy?
2. How long had you been in therapy? From when to when?
3. What kind of license, if any, did the therapist(s) hold? (M.D., PhD., MFCC, LCSW)
4. If you had to chose a category or categories to define the misconduct or malpractice, which of the following apply?
(Sexual contact, sexual suggestion or overture, other sexualization of therapy relationship, breach of confidentiality, misdiagnosis, misprescription of medications, improper termination of therapy, financial exploitation, dual relationships, other)
5. Briefly describe the misconduct or malpractice.
6. When did the misconduct or malpractice occur?
If over a period of time, approximately when was the first event, and when was the most recent?
7. When did you figure out the behavior was misconduct or malpractice? How did you figure it out?
8. Have you reported the misconduct or malpractice to anyone? To whom? When?
9. Have you sought any treatment for the emotional distress? (Doctor, therapist, counselor, etc.)
10. In addition to your emotional damages, have you suffered any financial loss? (Loss of job, demotion, medical bills, etc.)
Please fill out the form below to send us your responses in as a secure e-mail message. Again, all information you provide will be maintained in strict confidence. We will respond to your inquiry within 24 hours. Fields marked with an * are required.
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