Educational DVDs and Videos


The Cult Education Institute requires some basic information through the completion of the following intake questionnaire. If you have other questions, feel free make direct contact instead.

Please take the time to complete this form. At the bottom of the form, when you are done, press the "Submit Questionnaire" button to send the electronic form. Please also send any support documentation you feel might be meaningful. And remember to save letters, group literature and/or other relevant material that may be helpful.

Name:
Age:
Male/female
Home address:
Your phone number:
Work phone:
Best time to reach you at these numbers:
Your e-mail address:
Current work or profession:
Is your work somehow related to the group and/or leader in question?
Marital Status:
Spouses name?
How many children?
Ages of each child:
Name of group, leader or counselor:
Name of person most related to your situation in the group:
Name of local group and/or leader in your area:
Group location address:
How did you first come into contact with the group, leader and/or counselor?
Where & when did first contact with the group, leader and/or counselor occur?
What was the length of time you were involved?
Was anyone else, such as a friend, business associate and/or family member also involved?
What type of abuse, exploitation and/or personal injury did you suffer through your involvement with the group, leader and/or professional person in question? Describe this in some detail.
Approximately how long and/or how many times, did you suffer such abuse?
Did anyone else also experience personally injuries through abuse and/or exploitation that you can recall within or through the group, leader and/or professional person in question?
Did an adult or minor perpetuate this abuse?
Were any minors abused or harmed in any way through this situation?
Have you required professional care as a direct result of the abuse, which you have cited?
Has there been related physical and/or mental/emotional problems as a related result of this abuse? Explain.
Have you ever been ill within the group? Did you receive proper medical and/or other professional attention? Who paid for this treatment?
What money, material goods, property, etc. have you given to the group, leader and/or professional that is involved?
Were other members of your family, close friends or professional/business associates somehow also involved with the group, leader and/or professional person in question?
What specifically convinced you that the group, leader and/or professional person is destructive/harmful or negative?
Are you now in contact with other professionals concerning this situation? Please name any professionals or persons you have contacted.
Please include any additional information you feel might be helpful or in some way meaningful.
If you prefer, you may print this form out and then fax or mail your responses to The Cult Education Institute.

Someone associated with The Cult Education Institute will contact you.