Confidential Case Evaluation

We understand how difficult it is for you to tell your story of sexual abuse. But we want to listen, to hear you, and to help you on your path of surviving. In an effort to assist you, even if you are not yet ready to speak with an attorney, we are providing a screening intake. Should you want an opinion on your potential claim without the stress of speaking to someone about your situation, please answer the questions below. If at any time you want to speak to an attorney, our lawyers are ready to listen and guide you on the next steps of healing and ready to give you back your voice. If you are not ready to speak we will give you a written opinion on your potential claim free of charge.

Full Name
Date of Birth
MM slash DD slash YYYY
Place of Birth
Email*
Phone Number
Current Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Address at the time of the abuse
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Significant Personal Relationships
Education
Schools, dates of attendance, degrees awarded
Employment History Since H.S
Dates, name/address of employer(s), job title, job duties, salary/income/benefits, changes/termination dates and reasons
Detailed Outline/Chronology of Relevant Events:
Witnesses to the Events
Names and Addresses
Persons With Whom Abuse Discussed
Names and Addresses
Complaints To Licensing Authorities, Professional Societies, Others about Abuse
Names and Addresses
Medical/Mental/Emotional Condition Prior to Abuse
Changes in Medical/Mental/Emotional Condition Following Abuse
Treatments/Hospitalizations in Connection with Abuse
Medications, Both in Connection with Abuse and Otherwise
Describe how your condition worsened After Events
When first? How so? What action did you/others take in response?
Any Other Relevant Information You Want to Share