Intake Questionaire

Hiring Rick Ross for the purpose of an intervention usually starts with an Intake Questionaire. If you have other questions, feel free to contact him directly at the address, phone number, or email address at the bottom of this page.

Please take a few minutes and fill in this form. At the bottom of the form, when you are done, press the "Submit Intake Questionnaire" button to send the electronic form to Rick Ross. Please send any recent snapshots of the person involved to the address at the bottom of this form. Please remember to save all letters, group literature and take notes regarding related conversations and episodes that might be helpful.

Name of person you are concerned about:
Your Email Address:
Does he/she live at home with family?
If he/she does not live at home, with who does he/she live with?
Address:
Age:
Name Used in Group:
Physical description:

Height: Weight:
Race: Hair:
Eyes: Sex:

Educational background of person:

High School:
Standing:
College:
Major:

Military background:
Current work or profession:
Is his/her work in any way related to the group:
Marital Status:
How many children?
Ages of each child:
Length of time Person has been in the group:
Religious background:
Name of group:
Name of group leader:
Name of local leader of group:
Group location:
Where did first contact with group occur:
Your name and relationship to person involved:
Your address:
Your home phone number:
Your work phone number:
His/Her Father's name and occupation:
His/Her Mother's name and occupation:
His/Her parents marital status:
His/Her Father's and Mother's home address:
Children in his/her immediate family. List names and ages (including Client) in sequential order- oldest to the youngest:


1.   List any concerned persons. Such as relatives, friends, family-including yourself.

2.   Has he/she ever expressed any doubts or difficulties as a member? Explain.

3.   Describe family environment previous to involvement in the mentioned group. Have there been any fights or estrangement's that have impacted the family? Any sudden or significant changes? What has the atmosphere been like? Please be Explicit.

4.   Describe his/her significant relationships. Include details about best friends, boy/girl friends, and any close relatives.

5.   Who would not be willing to help in an intervention.

6.   Describe his/her state of mind just previous to joining the group. Please be detailed.

7.   How did he/she do in school? What kind of grades? How did he/she relate to friends? How much did he/she respond to peer pressure? What kind of involvement in extracurricular activities?

8.   Is he/she still in contact with old friends known previous to group involvement? Please name these friends. Are they still close? How have these relationships changed?

9.   Did he/she have close friendship prior to involvement in the group? Were these friendships made easily or with some difficulty? Explain.

10.   Is he/she particularly close to any one relative? If so, Who? Do you know why? Is that relative willing to help in an intervention effort?

11.   How do you feel that your relationship was before he/she entered the group? Has that changed since involvement? How?

12.   Have you had any confrontations with the client concerning the group? Please detail.

13.   Please give as complete a job history as possible of the client. List each job or position in chronological order.

14.   What travel experience has the client had? Have these experiences been alone or with family/friends? When and How did they take place?

15.   Was he/she actively training for, interested in, or participating in any sports activities?

16.   Has he/she ever been known to have violent episodes? If so please detail.

17.   Please describe his/her life style prior to joining the group.

18.   Did the client participate actively in his/her religious denomination prior to joining the current group? Does he/she have any close clergy or religious friends from these past experiences?

19.   What church group did he/she show interest in before this current group involvement? List in chronological order as best as possible.

20.   What specific personality changes have you noticed since he/she has joined the group in question? Describe in detail.

21.   To the best of your knowledge, has he/she given any unusual amounts of money, material goods, property, etc. to the group?

22.   Have you donated money to the group?

23.   Were you or any members of his/her family in any way involved with the group in question?

24.   Does he/she currently keep in regular contact with his family and friends? Does he/she call or wrote? How often? Has this changes from the rate of contact before group involvement? Be specific.

25.   If he/she does visit his/her family at home, does he/she come alone? If not, who accompanies him/her?

26.   Give your impression of visits, calls or letters since his/her involvement in the group. Do they seem spontaneous and normal or planned and recited?

27.   Has he/she ever been ill within the group? Did they receive medical attention? Who paid for this treatment?

28.   What is his/her source of income? Is the group any way related to this income?

29.   Has he/she been dating someone steadily? Is this person in any way associated with or acquainted with the group? What is their name, if known and length of time of this relationship.

30.   Has he/she mentioned any names of people in the group? Please list any names you recall and a brief description of these people if possible.

31.   Has there been any talk of the client leaving the country, being transferred to another location in the group or being involved in a marriage to someone within the group?

32.   Does he/she have a history of physical or mental illness? Any learning disabilities or physical handicaps?

33.   Has he/she ever been in counseling?

34.   Does he/she currently take medication? Wear contact lenses/glasses?

35.   Has he/she recently complained about physical or mental/emotional problems? Explain.

36.   Does he/she seem tired all the time?

37.   Does he/she use new phrases/jargon? Have you noticed a change in his/her vocabulary? Please list specific examples.

38.   Did he/she have particular political or social interests that have recently changed? Explain.

39.   Have his/her views on sexuality/morality changed? How? Has their behavior matched this change?

40.   Do you have any literature/books, press clippings, audio or video tapes regarding this group? Please list the type & title of this material.

41.   Has he/she always been a logical and critical thinker? Has this changed since the group involvement?

42.   Does he/se have a selfish and/or stubborn attitude? Has this changed since this group involvement?

43.   Describe his/her reading habits before group involvement: kinds of books, Fiction/non-fiction, historical, political or religious. Has this reading recently changed? How?

44.   Did he/she practice meditation or yoga prior to his/her group involvement?

45.   Did he/she attend any human potential/self-improvement workshops prior to group involvement? Please list them by name.

46.   Have his/her habits changed regarding diet, sleep, cleanliness? Explain.

47.   What organizations, professionals or individuals have you contacted for information or help regarding your concerns?

48.   What materials have you reviewed regarding your current concerns? Please list.

49.   What specifically has convinced you that the group you are concerned about is a destructive/harmful or negative group?

50.   Please explain your motivation for seeking an outside consultant concerning this problem?

51.   What expectations do you have if an intervention should take place?

52.   If the person involved should choose to belong to a different religious group, political party or social group than your own, can you accept that?

53.   Are you currently working with any mental health professionals concerning this situation, family counseling, or other consultation? Are they knowledgeable about destructive, totalist groups or mind-control?

54.   Have you attempted an intervention before? What was the result and who assisted you in this effort?

55.   Are you now in contact with other professionals concerning this situation? Please name any professionals or persons you have contacted.

56.   Has he/she expressed doubts or concerns about the group? To whom? When? What seemed to motivate this?

57.   How did you find RICK ROSS?

Please feel free to add any other information you feel would be valuable and meaningful.


Those concerned about security on the Internet may prefer to print this form out and fax or mail it to: