1. Select your state: Choose State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

New Jersey residents, select your county: Choose NJ County Atlantic Bergen Burlington Camden Cape May Cumberland Essex Gloucester Hudson Hunterdon Mercer Middlesex Monmouth Morris Ocean Passaic Salem Somerset Sussex Union Warren

2. How old was your son or daughter at first contact with the alienating influence?

16 or under

17-21

Over 21

3. Who tried to turn your son or daughter against your family? (Choose all that apply.)



Your family member’s friend or acquaintance

Family of your family member’s friend/acquaintance

Your family member’s boyfriend/girlfriend

Family of your family member’s boyfriend/girlfriend

Authority figure. Please specify:

Other. Please specify:

4. Did the alienating influence: (Choose all that apply.)

Make frequent or excessive contact with your family member via phone, text, email, or IM?

Contact your family member at inappropriate times, such as late at night or during school hours?

Question your family member about their upbringing or family environment, persuade them to share personal details, and/or criticize your family’s decisions and parenting style?

Instill unreasonable fears in your family member?

Ask your family member probing questions about their and/or your family’s savings/finances?

Encourage your family member to miss key family events and celebrations?

Insist that your family member not visit family unless accompanied by someone approved by the alienating influence?

Require your family member to maintain contact (by phone/text, for example) with the alienating influence during family visits?

Try to isolate your family member from longtime friends as well as relatives?

Offer your family member a reward of any kind (not necessarily money) for obedience to them?

Entice your family member with sex, either with them or with someone else?

Interfere with your family member’s decision-making process regarding major life choices, such as moving away from home, selecting a college, choosing a job, getting married?

Require your family member to get their advice/permission before making key decisions?

Insert themselves into your family member’s life as the go-to person for direction on all things from emotional issues to finances?

Try to convince your family member that you were controlling and/or that your relationship was unhealthy?

5. What kind of lifestyle changes did your family member make for the sake of the alienating influence? (Choose all that apply.)

Severed relationships with friends

Severed relationships with family

Left home

Quit school

Gave up a favorite activity. Please specify:

Altered belief system

Turned over savings/other source of income

Underwent a radical change in personality (for example, the family member you used to be close to became unusually secretive, distant, and/or fearful of you)

Underwent a radical change in appearance

Other. Please specify:

6. What did you do about the situation? (Choose all that apply.)

Retrieved the family member at his/her request

Retrieved the family member without his/her request

Asked family or friends to intercede

Contacted school officials for help

Contacted the police or other law enforcement agency

Consulted a lawyer

Consulted with the court system

Consulted clergy

Consulted a mental health professional or other helping professional

Contacted a legislator or other government official

Tried to reason with the alienating influence

Nothing

Other. Please specify:

7. Which statement best describes the current status of your situation?

I am in regular contact with my family member; our relationship is back to normal.

I have some contact with my family member, but our relationship is not back to normal.

There is no contact between me and my family member.







8. How old is that family member now?

16 or under

17-21

Over 21

9. How long did the alienation last/how long has it been going on? Duration:



10. May we contact you? If so, please enter your name and an email address or telephone number below:

Email:

Phone: