Profession
Please Select
Psychiatrist
Psychologist
Therapist
Counselor
Other
Other Profession
Negative Information is related to: (Choose all that apply)
Negative Reviews
Intentional slander, revenge or spiteful content
Arrest, Conviction or Accusation
State Disciplinary Action
Federal Offense
Sex Offense
Other
Which review websites (choose all that apply)?
HealthGrades.com
RateMD.com
Vitals.com
Angie's List
Bulletin Boards or Blogs
Other
Which State?
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
How many Disciplinary Actions?
Please Select
Only one
2 Disciplinary Actions
3 or more Disciplinary Actions
Disciplinary Actions in more than one state
Has the Board Action or Offense been listed on any of the following websites?
HealthGrades.com
PsychCrime.org
PsychSearch.net
National Register of Health Service Psychologists
Federal Health and Human Services Database
I don't know
Propagation of information - Has the information been replicated or duplicated on other websites?
No - it is only on 1 website
Yes - the information is on 2 to 5 websites
Yes - the information is on more than 5 websites
Yes - the information is on more than 10 websites
I don't know
Where is the negative information listed? (Choose all that apply)
Review Website(s) (Angie's List, Yelp, Rate MD, Health Grades, etc.)
Social Media (Facebook, Twitter, Google Plus, etc.)
State Board or State Website
Federal Website
Blogs or other websites
Newspaper website(s)
TV News or Video website(s)
I don't know
Other
Press Coverage: Has the information been covered in any of the following?
Press Releases
Newspaper Coverage
Local T.V. Coverage
National T.V. Coverage
No, none of the above
I don't know
Other
Impact: How is this information impacting you or your business?
It is a nuisance
It is embarrassing
It is costing me money
It is ruining my business
It is ruining my life
Description of circumstances – how and why the negative information is on the Internet?
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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Preferred Method of Contact
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Either
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