Reginald Archibald
Boy Scouts
Catholic Church
Youth Orgs
About Us
Contact Us

Reginald Archibald
Boy Scouts
Catholic Church
Youth Orgs
About Us
Contact Us

Step 1 of 19

Thank you for taking the time to provide the information requested in this online questionnaire. We will use this information in our negotiations and to aid our investigation regarding your claim.

Please do not guess or feel compelled to provide answers to questions if you do not know the answer. For example, if for some reason you cannot recall exact dates, please give us your best estimate and let us know that you do not recall specific dates. And please do not be alarmed if you cannot recall the dates as we will likely have other ways to obtain the dates. We understand that you will likely recall more information as time goes on, so please only provide the best information that you can today. You are always welcome to share more information with us, and we will likely have the opportunity to provide more information down the road.

We are providing this form because some people find it easier to provide the information in this fashion. Please let us know if you would rather provide this information over the phone.

Please know that the information you provide to us will be kept confidential and will not be shared with anyone else.
Name
Prefix First Middle Last
Date of Birth
Month
Day
Year
Social Security Number
Current Marital Status
- Married
- Single - Never Married
- Single - Divorced
- Singled - Spouse Deceased
How many years married?
Do you have any children, including: biological, adopted, or stepchildren?
- Yes
- No
How many children?

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What are the full names of your parents and/or guardian(s) at the time of the abuse?
First Last
Are your parents or your other guardian(s) at the time of the abuse alive?
- Yes
- No
Would you be comfortable with us talking with your parents about the abuse if we first talked with you before reaching out to them?
- Yes
- No
Do you have any siblings?
- Yes
- No
List
Sibling First Name Sibling Last Name Sibling Birthdate Deceased?
Would you be comfortable with us talking with your sibling(s) about the abuse if we first talked with you before reaching out to them?
- Yes
- No

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Residence History

Please list all your places of residence since birth and indicate the duration of residency for each

Address Line 1	Address Line 2	City	State	Zip	Residence Start Month	Residence Start Day	Residence Start Year	Residence End Month	Residence End Day	Residence End Year

Residence History
Please list all your places of residence since birth and indicate the duration of residency for each
Address Line 1 Address Line 2 City State Zip Residence Start Date Residence End Date
State and Federal Assistance
- Yes
- No

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State and Federal Assistance History

Have you ever seen, consulted with, or received assistance of any sort from any federal, state, or local social welfare, vocational, rehabilitation or service agency, including Medicare or Medicaid?

Agency Name	Agency Address Line 1	Agency Address Line 2	Agency City	Agency State	Agency Zip	Agency Start Month	Agency Start Day	Agency Start Year	Agency End Month	Agency End Day	Agency End Year	Names of People Who Worked With You	Nature of the Services Provided by the Agency

State and Federal Assistance History

Have you ever seen, consulted with, or received assistance of any sort from any federal, state, or local social welfare, vocational, rehabilitation or service agency, including Medicare or Medicaid?

Agency Name	Agency Address Line 1	Agency Address Line 2	Agency City	Agency State	Agency Zip	Agency Start Date	Agency End Date	Names of People Who Worked With You	Nature of the Services Provided by the Agency

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Have you ever filed for bankruptcy?
- Yes
- No
When did you file For bankruptcy?
Month
Day
Year
In what state did you file for bankruptcy?
What bankruptcy chapter did you file under?
- Ch. 7
- Ch. 11
- Ch. 13
- Other
Please Explain
If you filed for bankruptcy jointly or for a business, please state the name(s) of the other person(s)/business(es):
What was the amount of discharge received, if any?

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What is your highest level of education?
- Left High School Before Graduation
- High School Graduation
- GED
- 2-Year College
- 4-Year College
- Post-Graduate Degree
- Other
Please Explain

Please list your complete educational background, including high school, college, university, graduate, trade or vocational schools, and/or correspondence classes as well as any professional licenses held.

Type of School	School Name	School Address Line 1	School Address Line 2	School City	School State	School Zip	School Start Date	School End Date	Type of Degree or Certification Received

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Are you employed?
- Yes
- No
Current Employer
Name
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Employment Start Date
Month
Day
Year
Your Position
Your salary or rates of compensation
Your benefits
The names of your supervisor(s)
First Name Last Name

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Employer Name	Employer Address Line 1	Employer Address Line 2	Employer City	Employer State	Employer Zip	Position	Salary or Rates of Compensation	Benefits	Name(s) of your Supervisor(s)	Employer Start Month	Employer Start Day	Employer Start Year	Employer End Month	Employer End Day	Employer End Year	Reason for Leaving

List your complete employment history

Employer Name	Employer Address Line 1	Employer Address Line 2	Employer City	Employer State	Employer Zip	Position	Salary or Rates of Compensation	Benefits	Name(s) of your Supervisor(s)	Employer Start Date	Employer End Date	Reason for Leaving

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Type of Case

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In which state did the abuse primarily occur?
Did the abuse occur in any other states?
- Yes
- No
Which other state(s) did abuse occur?
Info about the abuser(s)
Name How would you describe the abuser’s physical appearance? To your knowledge, is the abuser still alive? What was the role of the abuser(s)?
Info about the abuser(s)
Name How would you describe the abuser’s physical appearance? To your knowledge, is the abuser still alive? What was the role of the abuser(s)?
Info about the abuser(s)
Name How would you describe the abuser’s physical appearance? To your knowledge, is the abuser still alive?
Info about the abuser(s)
Name How would you describe the abuser’s physical appearance? What was the role of the abuser? To your knowledge, is the abuser still alive?
Where did the abuse occur?
What was the name and address of the school?
Name
Street Address Address Line 2 City State ZIP Code
Did the abuse take place on the grounds of a foster home or other foster care agency facility?
- Yes
- No
If you remember it, please state the name of the facility or the address of the home where the abuse took place
Name
Street Address Address Line 2 City State ZIP Code
If you remember it, please state the name of the agency or agencies that placed you in the foster home or other facility where the abuse took place:
What is/was the name and address of the church where the abuse took place?
Name
Street Address Address Line 2 City State ZIP Code
Is the church affiliated with any larger denomination/sect?

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Did the abuse occur on the grounds of the school?
- Yes
- No
Where did the abuse occur?
Did the abuse occur during a school activity?
- No
- Yes
What was the nature of the home or facility where the abuse took place?
- Residential foster home
- Group home
- Juvenile detention facility
What was the role of the abuser?
- Foster parent
- Foster sibling
Did CPS or any other agency intervene because of the abuse
- Yes
- No
Please indicate which agency
What action did CPS or other state agency take regarding the abuse?
Some religious leaders have their assignments moved, including transfers as a result of child abuse. We will work to find this information, but please let us know if you believe your abuse may have involved more than one Church, such as a person who was transferred from another Church or school before they abused you. Did the abuse involve more than one Church/entity?
- Yes
- No
Which one(s)?
Is the Church affiliated with a school or university?
- Yes
- No
What was the name and address of the school?
Name
Street Address Address Line 2 City State ZIP Code

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Do you believe you know the approximate date, month, or year that you believe he or she first abused you? We know this may be difficult to remember, so please do not guess. If you cannot approximate, please check “I am not sure.”
- I believe I can approximate the date of the first inappropriate encounter
- I believe I can approximate the month of the first inappropriate encounter
- I believe I can approximate the year of the first inappropriate encounter
- I am not sure
Date
Month
Day
Year
Month
Year
How many times do you believe he or she acted inappropriately with you? We realize this may be difficult to remember, or to know with certainty, so please just answer to the best of your memory.
Do you believe you know the approximate date, month, or year that you believe he or she last did anything inappropriate with you? Again, we know this may be difficult to remember, so please do not guess. If you cannot approximate the last time you believe he or she may have done something inappropriate with you, please pick “I am not sure.”
- I believe I can approximate the date of the last inappropriate encounter
- I believe I can approximate the month of the last inappropriate encounter
- I believe I can approximate the year of the last inappropriate encounter
- I am not sure
Date
Month
Day
Year
Month
Year

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If you are comfortable sharing this information, please select each of the inappropriate things that you recall him or her doing to you. We know this is difficult to provide, but we need this information to help try to resolve your claim.
- He or she removed my clothes
- He or she asked me to remove my clothes
- He or she took naked pictures of me
- He or she touched my breasts over clothing
- He or she touched my breasts under clothing
- He or she touched my buttocks over clothing
- He or she touched my buttocks under clothing
- He or she touched my genitals over clothing
- He or she touched my genitals under clothing
- He or she asked me to masturbate
- He or she asked me to masturbate him or her
- He or she asked me to touch him or her in a sexual way
- He or she had me perform oral sex on him or her
- He or she performed oral sex on me
- He or she had sexual intercourse with me
- Other
To the best of your ability, describe the nature and extent of the sexual abuse:
Was anyone ever present during any of the conduct that you identify above?
- Yes
- No
- I can't remember
Who was present?
- My Parent(s)
- Another Student
- Another Church Leader
- Another Usher
- Another Lay Person
- Another Person who Worked at the Church
- A Deacon
- A Sibling
- Other
Who was present?
- My Parent(s)/Foster Parent(s)
- Another Student
- Another Foster Child
- Court Appointed Special Advocate (CASA)
- A religious figure
- An Employee of the group home/facility
- A friend
- A Sibling
- Other
Who was present?
- My Parent(s)/Guardian(s)
- Another Student
- Another Teacher
- An Employee of the school
- A friend
- Other
Who else was present?
If you know, how and why did the abuse come to an end?
How do you think the abuse has affected you and impacted your life? Please check any of the following issues that may apply. In addition, feel free to write a response in your own words by selecting “other.”
- Anxiety
- Academic (Poor performance in school)
- Anger
- Attempted Suicide
- Depression
- Flashbacks
- Guilt
- Hypervigilance
- Marriage Problems (e.g. Divorce)
- Nightmares
- Problems with Anxiety
- Professionally (Failure to reach full potential)
- Sexual Dysfunction
- Sexual Intimacy problems
- Shame
- Sleep Problems
- Substance Abuse
- Suicidal Thoughts
- Trust Issues
- Other
In your own words, please describe how the abuse has affected you and impacted your life.

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We normally must prove the Church knew or should have known that the person who abused you posed a danger to children. Although the Church may now admit that the person was an abuser, the Church may not be legally responsible for what happened to you unless we can show the Church knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that the foster care agency or the state knew or should have known that the person who abused you posed a danger to children. Although the foster care agency or the state may now admit that the person was an abuser, the foster care agency or the state may not be legally responsible for what happened to you unless we can show that they knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that the school knew or should have known that the person who abused you posed a danger to children. Although the school may now admit that the person was an abuser, the school may not be legally responsible for what happened to you unless we can show the school knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
We normally must prove that an entity knew or should have known that the person who abused you posed a danger to children. Although the Defendant may now admit that the person was an abuser, the Defendant may not be legally responsible for what happened to you unless we can show the Defendant knew or should have known that you were in danger before or during the time you were abused. We refer to this as “notice evidence” and it is critical evidence for your case – without it we may not be able to prove your case. These questions are designed to help us find such “notice evidence.”
Can you think of any reasons why someone else might have known or suspected that you were being abused? For example, did anyone see you spending too much time alone with the abuser, or did someone see you with the abuser after hours or in a place where children were not normally allowed to go?
- Yes
- No
Why do you think someone else might have known or suspected that you were being abused?
Can you think of anyone else who may have been abused by the same person?
- Yes
- No
Who do you think may also have been abused by the same person?

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We know that most children do not ever tell anyone about sexual abuse, but when you were a child did you ever tell anyone that you did not like the perpetrator or that (s)he had done something inappropriate to you?
- Yes
- No
Who did you tell and what did you tell them?
Name of Person You Told Approximate Year You Told Them What Did You Tell Them?
Please do your best to compile a list of all people you remember having possible contact with the perpetrator, even if you don’t think they were abused by the perpetrator.
Name Position
Do you believe that anyone else may have ever complained about abuse or inappropriate behavior by the person who abused you? If any, please list why you believe the person complained.
Name of Person Why You Believe They Complained

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Do you have a yearbook or roster from the Church/school or are you able to get one?
- Yes
- No
Do you recall whether the Church issued a directory or photo directory to members?
- Yes
- No
Do you have a directory?
- Yes
- No
Do you currently have any records from your time at the school, such as report cards, rosters, or letters to or from employees of the school?
- Yes
- No
Please email call Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Do you have any yearbooks or other records from the time period when you were abused that might have the names of other kids who were your same age?
- Yes
- No
Please email call Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. If you know of someone who may have these types of records, please email Jessica Burrus at jessicab@pcvalaw.com so that we can try to obtain them.
Please immediately email Yemi Ajayi at yajayi@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Yemi Ajay at yajayi@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Do you your parents or siblings have yearbooks or other records from the time period when you were abused that might have the names of other kids who were your same age?
- Yes
- No
Please email Jessica Burrus at jessicab@pcvalaw.com to let her know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Jessica Burrus at jessicab@pcvalaw.com so that we can try to obtain them.
Please immediately email yajayi@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Yemi Ajayi at yajayi@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.
Please immediately email Tim Brothwell at tbrothwell@pcvalaw.com and let him know you have these records. We may interview other children because they may have complained about the abuser or they may know of someone else who complained about the abuser. Please do NOT reach out to potential witnesses on your own.
Please think hard about this question. These types of records can help us identify other witnesses who may have complained about your abuser. It is OK if you do not have these types of records, but please give it some hard thought. If you know of someone who may have these types of records, please email Tim Brothwell at tbrothwell@pcvalaw.com and let him know so that we can try to obtain them.

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Have you ever maintained a journal, calendar, or diary that refers to the events of the abuse?
- Yes
- No
Do you still have these materials in your possession?
- Yes
- No
Have you ever corresponded with anyone in writing about the abuse, including with the abuser?
- Yes
- No
Do you still have that correspondence in your possession?
- Yes
- No
Please explain the format in which you have that correspondence, for example, in the form of text messages, a letter written in reply, etc.:

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Have you ever posted on social media about the abuse?
- Yes
- No
On which platform did you post?
- Facebook
- Twitter
- Instagram
- Other
What other platform?
Please list the dates or approximate dates of all of the posts about the abuse
Month Day Year
Which accounts and posts do you still have access to?
- Facebook
- Twitter
- Instagram
- Other
What other platform?
Have you ever told anyone about the abuse?
- Yes
- No
To the extent that you are able, please list the names, relationships to you, contact information, and approximates dates when you told each person about the abuse. Please do NOT reach out to potential witnesses on your own.
Name Address Line 1 Address Line 2 City State Zip Phone Number Email Date Relationship

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Have you ever sought counseling which you now believe was directly or indirectly related to the abuse?
- Yes
- No
Please explain why you believe the counseling was related to the abuse:
Approximately what year did you first receive counseling?
Approximately how long did you participate in counseling?
Over the course of your life have you had any out-of-pocket expenses for the abuse? For example, have you paid for counseling or medication?
- Yes
- No
Please provide a description and dollar amount for each out-of-pocket expense you have incurred as a result of the abuse, for example, for counseling or medication.
Expense Description Expense Amount ($ Amount) Do you have billing records, receipts, or invoices for these expenses?

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Please list all physicians, therapists, psychologists, psychiatrists, medical institutions, counselors, clergy, social service organizations or other physical or mental health care providers who have ever examined or treated or consulted with you for anything related to the abuse.

Provider Name	Provider Address Line 1	Provider Address Line 2	Provider City	Provider State	Provider Zip	Provider Telephone Number	Treatment Start Month	Treatment Start Day	Treatment Start Year	Treatment End Month	Treatment End Day	Treatment End Year

Please list all physicians, therapists, psychologists, psychiatrists, medical institutions, counselors, clergy, social service organizations or other physical or mental health care providers who have ever examined or treated or consulted with you for anything related to the abuse.
Provider Name Provider Address Line 1 Provider Address Line 2 Provider City Provider State Provider Zip Provider Telephone Number Treatment Start Date Treatment End Date

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Do you want to file your claim?
- Yes
- No
- Maybe

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Thank you very much for taking the time to complete this questionnaire. Is there anything else that you would like us to know about your answers or about any other issue?

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Call Us: 1-888-811-8689

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Marsh Law Firm PLLC, 151 East Post Road, Suite 102, White Plains, NY 10601, and Pfau Cochran Vertetis Amala PLLC, 701 Fifth Avenue, Suite 4300, Seattle, WA 98104, are responsible for the content on this website. James Marsh, Jennifer Freeman, Robert Lewis, Darrell Cochran, and Anelga Doumanian are licensed to practice law in New York. However, some lawyers from Pfau Cochran Vertetis Amala PLLC, including Michael Pfau, Jason Amala, and Vincent Nappo, are not licensed to practice law in New York. Attorney Katie Shipp is licensed to practice law in Pennsylvania. If a potential client contacts an attorney through this website, the potential client may be referred to one of the New York licensed attorneys from Marsh Law Firm PLLC depending on the type of case, the location where the abuse or injury occurred, and the current location of the potential client. None of the non-New York licensed attorneys employed by either Marsh Law Firm PLLC or Pfau Cochran Vertetis Amala PLLC can or will render legal services in the State of New York without having first been duly and regularly licensed and admitted to practice in New York courts of record, including by admission to the practice of law in the state of New York pro hac vice, or through the temporary practice of law in New York in accordance with 22 NYCRR Part 523. See http://www.nycourts.gov/ctapps/523rules.htm

ATTORNEY ADVERTISING. This website is attorney advertising that is intended to provide general information to survivors of childhood sexual abuse. Every case is different, so the general information on this website is not intended to provide legal advice and no attorney/client relationship exists as a result of the general information provided by this website.

1-888-811-8689

Sibling First Name	Sibling Last Name	Sibling Birthdate	Deceased?

Name	How would you describe the abuser’s physical appearance?	To your knowledge, is the abuser still alive?	What was the role of the abuser(s)?

Name	How would you describe the abuser’s physical appearance?	What was the role of the abuser?	To your knowledge, is the abuser still alive?

Name of Person You Told	Approximate Year You Told Them	What Did You Tell Them?

Expense Description	Expense Amount ($ Amount)	Do you have billing records, receipts, or invoices for these expenses?

Name of Person	Why You Believe They Complained