Elder Abuse and Nursing Home Abuse

We understand that discussing elder abuse or nursing home abuse can be difficult. This questionnaire is designed to help us understand your experience and connect you with the legal resources and support you need. Please answer as much as you feel comfortable. If a question doesn't apply or feels too difficult, feel free to skip it.

Please select the options that apply to you. You can skip any questions that don't feel relevant.

Your responses are completely confidential and will only be shared with our representatives for the purpose of evaluating your case. We are committed to protecting your privacy and supporting you throughout this process.

Name*

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Email*

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I Agree to the Privacy Policy, Terms of Use, and Legal Disclaimer*

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I consent to providing this information and understand it will be used to assess my legal options. I understand this is not legal advice and does not create an attorney-client relationship.*

What type of unwanted experience have you or your loved one been exposed to:

Physical Abuse

Emotional/Psychological Abuse

Financial Exploitation

Neglect

Sexual Abuse

Other (please specify)

Please describe:

When did this experience occur, or when was the most recent experience if ongoing? If you don't know the exact date, please select the approximate date and / or year.

MM slash DD slash YYYY

Please describe the situation and share any details you feel comfortable with regarding the nature of the abuse or neglect.

Can you provide the name of the person(s) or institution(s) involved? If so, please provide their full name(s) and any information you have about them such as their; address, phone #, email, place of work, etc.

What is your relationship, or your loved one's relationship, to this person, people, or institution?

Family Member

Caregiver

Nursing Home Staff

Assisted Living Staff

Other (please specify)

What other relationship did you or your loved one have to this person, people, or institution?

Where did this experience occur?

Victim's Home

Nursing Home (please specify)

Assisted Living Facility (please specify)

Other (please specify)

What is the name and address of the facility?

Please select all the options that apply to how this experience has impacted you and / or your loved one:

Physical injuries (please describe)

Emotional distress (anxiety, depression, PTSD, etc

Financial difficulties (loss of savings, unusual financial transactions)

Decline in health or well-being

Other (please specify)

Please describe the physical injuries:

How else has this experience impacted you and / or your loved one?

Have you or your loved one sought any medical treatment or counseling as a result of this experience? If yes, please provide details.

Have you shared this experience with anyone?

Yes

Please specify who you shared this experience with (e.g., police, Adult Protective Services, long-term care ombudsman, etc.):

What was the outcome of sharing this information?

Have you previously contacted, or are you currently represented, by another lawyer regarding your case?

Yes

Please specify who you contacted or which lawyer you are currently represented by:

Is there anything else you'd like to share that you think could be helpful?

(e.g., Names of people who may have witnessed the incident, any evidence you have in your possession, like photographs, medical records, financial statements, etc, or anything else you think would help us understand your experience.)

Your responses are completely confidential and will only be shared with our representatives to evaluate your case. We are committed to protecting your privacy and supporting you throughout this process. A representative from 1-888-I-SAID-NO will contact you soon or at your scheduled appointment time.

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Elder Home Abuse and Nursing Home Abuse Form

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