We hear you!

Name *

First Name

Last Name

Phone

Country

(###)

###

####

Have you travelled outside the country? *

Yes

No

Do you believe you are being followed? *

This includes on-line or in person

Yes

No

I am not sure

Do you notice any patterens? *

Cars, Colors, People, Actions

Yes

No

Are there any key words or phrases being used?

Example: "Money"," Sick", Coffing irregularly.

Yes

No

Are you having physical symptoms? *

Yes

No

I am not sure

Have you ever been a victim of a violent crime? *

Yes

No

Are your electronic devices acting strange?

Is your phone acting like a Ouija (wigi) board or auto clicking?

Yes

No

Is anyone asking you for money that you never met? *

Do not include charities and homeless persons unless it is a noted pattern.

Yes

No

Is someone breaking into your home and leaving things out of place or are your neighbors repeating patterns by tapping or using some other audible sound? *

Yes

No

Are you hearing a high pitched noise? *

Yes

No