Order Form - Psychologist Reputation Repair

Profession
Other Profession
Type of Practice
Negative Information is related to: (Choose all that apply)

None - 24/7 Practice Monitor OnlyNegative ReviewsIntentional slander, revenge or spiteful contentArrest, Conviction or AccusationState Disciplinary Action(s)Federal OffenseSex OffenseOther
Which State?
Has the information been listed on any of the following websites?

HealthGrades.comPsychCrime.orgPsychSearch.netNational Register of Health Service PsychologistsFederal Health and Human Services DatabaseI don't knowOther
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.)Official State Board or State WebsiteFederal WebsiteBlogs or other websitesNewspaper website(s)Other (Please list below):Other
Which review websites (Choose all that apply)?

HealthGrades.comRateMD.comVitals.comYelp.comAngie's ListOther
Press Coverage: Has the information been covered in any of the following?

Press ReleasesNewspaper CoverageLocal T.V. CoverageNational T.V. CoverageNone of the aboveOther (Please list below):Other
Propagation of information - Has the information been replicated or duplicated on other websites?

No - it is only on 1 websiteYes - Information is on 2 to 5 websitesYes - Information is on more than 5 websitesYes - Information is on more than 10 websitesI don't know
Level of Reputation Repair required (we will verify before we send you the contract)
Impact: How is this information impacting you or your business?

It is a nuisanceIt is embarrassingI would prefer people didn't know about itI could lose my jobIt is costing me moneyIt is ruining my businessIt is ruining my lifeOther
Description of circumstances – how and why is the negative information is on the Internet?
Name*

First NameLast Name
Phone Number
E-mail (Valid email required to complete order)*
Address

Street Address

Street Address Line 2

CityState

Zip Code
Preferred Method of Contact

PhoneEmailEither
Would you like to schedule a conference call?

YesNo, email is fine
Date you would like us to call?

MonthDayYear
Time you would like us to call?

:HourMinutesAM/PM Option
Special Offer/Coupon Code
Comments/Special Requests
Please verify that you are human*
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