First Name
Last Name
Middle Initial
Organization (if applicable)
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL
Birth Date
Gender	Male Female

1A	Are you a former member of a cultic group? Yes No
1B	Are you a family member or friend of a person who was involved in a cultic group?  Yes No
1C	Are you a helping professional? Yes No
1D	If you are none of the above, what would you call yourself?
2	Name of group to which ex-member belonged (or name of leader if the group has no name):
3	Year/month that ex-member joined group (approximate): Yr (2000) Mo (12)
4	Year/month that ex-member left (approximate): Yr (2000) Mo (12)
5	Religion in which ex-member was raised: Buddhist Christian: Eastern Orthodox Christian: Protestant Christian Roman Catholic Confucianism Daoism Hindu Jewish Muslim None Other
6	Protestant - specify denomination
7	Other - specify
8	Religion that ex-member currently practices: Buddhist Christian: Eastern Orthodox Christian: Protestant Christian: Roman Catholic Confucianism Daoism Hindu Jewish Muslim None Other
9	Protestant - specify denomination:
10	Other - specify:
11	After ex-member left his/her group, did he/she ever seek assistance from a church, synagogue, or other mainstream religious organization? Yes No
12	If yes, please rate the helpfulness of this assistance.  not at all helpful somewhat helpful helpful very helpful
13	If yes, please describe who helped you and what kind of help you received or sought but did not receive:
14	If assistance at a mainstream religious organization, such as a church/synagogue, had been available to ex-member when he/she left the group, how likely would he/she have been to take advantage of it? very unlikely unlikely uncertain likely very likely
15	If ex-member needed help for family, friends or him/herself when he/she left the group, please indicate below who needed help by checking all that are applicable. yourself siblings    How many? spouse children   How many? parents friends or other family
	Please rate the degree to which the ex-member or others who left with him/her needed the particular service when he/she left the group.  If more than one person needed the service, give the rating for the person who needed it most.
	Service	not needed	slight need	moderate need	high need	extreme need	don’t know
16	Housing
17	Medical Services
18	Transportation
19	Childcare
20	Legal Guidance
21	A Job
22	Financial Guidance
23	Employment/Vocational Guidance/Training
24	Therapist
25	Specialist on Cults
26	Support Group
27	Food
28	Clothing
29	$ for Incidentals
30	Educational Counseling
31	Paperwork (e.g., Photo ID, Birth Certificate, Social Security Number)
32	Health Insurance
33	Information on Cults
34	Spiritual Guidance
35	Other
36	Please describe below any other factors that you believe we should consider in trying to develop a network of churches, synagogues, and other mainstream religious organizations that can serve as resources for former members of cultic groups.