Case Evaluation Intake Form Clergy Abuse Evaluation Step 1 of 2 0% What Is Your Date of Birth(Required) MM slash DD slash YYYY What year did the abuse occur?(Required)Select Year:19601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000After 2000In which Diocese did the abuse occur?(Required)Select One:Diocese of California (Episcopal)Diocese of FresnoDiocese of MontereyDiocese of Northern California (Episcopal)Diocese of OaklandDiocese of OrangeDiocese of SacramentoDiocese of San BernardinoDiocese of San DiegoDiocese of San Diego (Episcopal)Diocese of San FranciscoDiocese of San Joaquin (Episcopal)Diocese of San JoseDiocese of Santa RosaDiocese of StocktonDiocese of El Camino Real (Episcopal)OtherWhat Was The Name Of The Diocese?(Required) Did the abuse occur at a Parish?(Required)Select One:YesNoWhat is/was the name of the Parish?(Required) Where did the abuse occur?(Required) What was the position/role/title of the abuser?(Required) How would you describe the type of abuse?(Required)When authoring your comments please try to include the Who? What? Where? When? and How?What was the impact of the abuse?(Required)Please describe in your own words how you have been impacted by the abuse. You do not have to go into great detail at this time. Did you/they ever tell anyone before or during abuse?(Required)Select One:YesNoWho did you/they tell before or during abuse?(Required) Did you/they ever tell anyone after the abuse was over?(Required)Select One:YesNoWho did you/they tell after the abuse was over?(Required) Can you/they think of any “red flags” that might have been witnessed by others?(Required)Select One:YesNoRed Flags(Required)In your own words can you briefly describe the red flags, including who may have witnessed the red flags.Can you/they think of anyone else who may have been abused by the same person?(Required)Select One:YesNoWho do you/they think may also have been abused by the same person?(Required) Was any investigation ever done of their abuse or the abuser?(Required)Select One:YesNo Δ
