WPI Investigation Request
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Name (first and last)
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Address:
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Valid email address
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Home Phone
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Work Phone
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Type of activity
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Witnesses
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Where has the activity taken place?
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Are there children involved between the ages of newborn and sixteen years?
Yes
No
If the answer to the previous question is yes, please state their names, ages, and genders.
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Are the children being affected by the activity?
Yes
No
If yes, please explain
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General description of home/business
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Has there been recent construction or other alterations in the home/business?
Yes
No
If yes, please explain
Has the home/business ever had exorcisms or blessings performed? If yes, please explain when and why.
If no, you may leave this section blank.
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To your knowledge, has anyone died on the property?
If so, please explain
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Please list the names and contact information (if known) of previous owners.
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Did you or any other witness to this activity use alcohol
24 hours prior to the event? If so, how much?
1-3
4-6
+7
NONE
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Do you or does anyone else in your home/business use prescription drugs? If so, p
lease select the appropriate causes.
Sleeping aids/pills
Mood Alterations (mood swings)
Psychotropic
Depression
Headaches
Pain management
Steroids
Anxiety
Other (not listed)
Valium
None
Muscle Relaxants
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Do you, or does the person experiencing the events, sleep well?
Yes
No
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If the answer to the previous question is no, please explain.
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Do you, or does the person being affected, suffer from nightmares? If so, please explain.
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How and/or what do you feel in the home/business? Please check all that apply
Nervous
Afraid
Sad
Confused
Angry
Happy
Watched
Tired
Heavy/Weighed down
Grief
Pressure (physical)
Tingly
Cold
Hot
Safe
Comforted
Welcomed
Unwelcome
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Please use this space to share any other information you feel we need to be aware of that has NOT been asked.
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DATE:
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