NAME (please print) ________________________________ DATE _________________
Please be sure to print the previous page and fill in your name and address. Then mail these two pages together to False Memory Syndrome Foundation, 3401 Market Street, suite. 130, Philadelphia, PA, 19104-3315. Note: All information will remain confidential.
I am contacting the Foundation because:
___ I have, or someone in my family has, been accused of abuse. Please complete section A.
___ I have (or have had) memories of abuse. Please complete section B.
___ I have a professional interest. Please complete section C.
___ I have a general interest in this topic.
Section A : Information about the accused.
Your relationship to the accuser:    Parent __    Sibling __    Grandparent__ Other _______
Accuser's gender:    Male__ Female__                     Accuser's year of birth: _______
Who is accused?    Mother __ (age ___)    Father __ (age ___)    Sibling __    Grandparents __
     Other ____________________
What year were you informed of the accusations? _______ 
Do the accusations involve recovery of "repressed" memories? Yes __ No __ Don't know __ 
Do the accusations involve satanic ritual abuse?  Yes __ No __ Don't know __ 
Is there contact with the accuser? Yes __ No __ If yes, who has contact? accused __ other _____ 
Is legal action involved? Yes __ No __ Has the accuser retracted? Yes __ No __ 
Section B : Information about those who have, or who have had, memories of abuse.
Your gender: Male __      Female __      Your year of birth _____
Did you have memories of abuse that you always remembered?  Yes __  No __
Did you recover memories of abuse while you were in therapy? Yes __ No __
What was your reason for entering therapy? ______________________________
Which of the following best describes your current view of your recovered memories?
Accurate ____ False _____ Uncertain _____
Did the memories include satanic ritual abuse?  Yes __  No __
Did your diagnosis include MPD? Yes __ No __
Is legal action involved? Yes __ No __
Please add anything else you think is important: _____________________________________
_______________________________________________________________________________ 
Section C : Information about those with a professional interest in the Foundation.
Check the category that best describes your professional field: Business __ Clergy __
    Education __ Government __ Law Enforcement __ Legal __
    Medical __ Mental Health __ Other ________________________ 
If you checked legal which of the following is most accurate?     Attorney __     Judge __
     Paralegal __     Other _________________________
If you checked mental health which of the following is most accurate? Psychiatrist __
   Psychologist (Ph.D. level) __ Psychologist (masters level) __ Social Worker __
   Counselor (LPC, MFCC, MA) __ Other ________________