What best describes the situation you are reporting?

Abuse, neglect, or assault that occurred at a Hospital, Clinic, or other Medical Facility. Abuse or neglect involving another type of organization (e.g., school, daycare, church). Abuse by a private individual, not connected to an organization. Another type of legal issue.

To ensure we are the right firm for you, please clarify the nature of the incident. This information remains completely confidential.

The incident(s) involved inappropriate sexual conduct (such as unwanted touching, exposure, or assault) and/or serious physical abuse, neglect, or medical malpractice. The incident(s) involved only verbal comments or other non-physical issues.

What was the role of the person responsible? (Select all that apply)

Doctor Nurse Therapist / Counselor Medical Staff / Technician Administrator Other

Approximately when did the most recent incident occur?

Please provide a brief, confidential summary of what happened. (Optional, but helpful)

First Name

Last Name

Email

Phone

State

Confidential Medical Facility Intake Form

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