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— For those who know of an alienation outside their own family
If you know of more than one instance, please fill out a separate Questionnaire C for each. (If you are the parent of a child who has been or is now being alienated from your family, please answer Questionnaire A.) (If you have been or are now being turned against your family, please answer Questionnaire B.)
If you know of more than one instance, please fill out a separate Questionnaire C for each.
(If you are the parent of a child who has been or is now being alienated from your family, please answer Questionnaire A.)
(If you have been or are now being turned against your family, please answer Questionnaire B.)
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 the member of that family at first contact with the alienating influence?
16 or under 17-21 Over 21
3. Who tried to turn that person against his/her family? (Choose all that apply.)
The person’s friend or acquaintance
Family of the person’s friend/acquaintance
The person’s boyfriend/girlfriend
Family of the person’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 the person via phone, text, email, or IM?
Contact the person at inappropriate times, such as late at night or during school hours?
Question the person about his/her upbringing or family environment, persuade him/her to share personal details, and/or criticize his/her parents’ decisions and parenting style?
Instill unreasonable fears in the person?
Ask the person probing questions about his/her savings/finances or those of his/her parents?
Encourage the person to miss key family events and celebrations?
Insist that the person not visit family unless accompanied by someone approved by the alienating influence?
Require the person to maintain contact (by phone/text, for example) with the alienating influence during family visits?
Try to isolate the person from longtime friends as well as family?
Offer the person a reward of any kind (not necessarily money) for obedience to them?
Entice the person with sex, either with them or with someone else?
Interfere with the person’s decision-making process regarding major life choices, such as moving away from home, selecting a college, choosing a job, getting married?
Require the person to get their advice/permission before making key decisions?
Insert themselves into the person’s life as the go-to person for direction on all things from emotional issues to finances?
Try to convince the person that his/her parents were controlling and/or that their relationship was unhealthy?
5. What kind of lifestyle changes did that person 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 person became secretive, distant, and/or fearful of people he/she used to be close to)
Underwent a radical change in appearance
6. What did the family 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
7. Which statement best describes the current status of that situation?
The family is in regular contact with their relative; their relationship is back to normal. The family has some contact with their relative, but the relationship is not back to normal. There is no contact between the family and the alienated relative.
8. How old is the person who was turned against his/her family now?
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:
Name:
"The family is the natural and fundamental group unit of society and is entitled to protection by society and the State."
— Article 16.3, Universal Declaration of Human Rights of the United Nations
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