First Name
Email Address
Cell Phone
Date
In what Time Zone are you located?
How often do you speak to (including online, phone) and or see your child or children?
Preferred Group Format
Online (Zoom/Video)
In-Person (Community Center)
One-on-One Introduction
A Brief Message (Optional)
How often do you speak to your child?
Were you involved in a high-conflict divorce?
Please briefly explain why you believe you are an alienated parent.
Type your full name as signature
Factor 1: A breach in the relationship
Factor 2: A prior positive relationship between the child and the parent whom the child is currently rejecting.
Factor 3: Absence of abuse or neglect or seriously deficient parenting on the part of the now rejected parent.
Factor 4: Evidence that the favored parent has engaged in many of the 17 primary parental alienation strategies.
Factor 5: Evidence that the child is exhibiting the eight behavioral manifestations of alienation.
Note: All 5 Factors must be present to justify an alienation claim
Strategy 1: Badmouthing
Strategy 2: Limiting Contact
Strategy 3: Interfering with Communication
Strategy 4: Interfering with Symbolic Communication
Strategy 5: Withdrawal of Love
Strategy 6: Telling the Child Targeted Parent Does Not Love Him or Her
Strategy 7: Forcing the Child to Choose
Strategy 8: Creating the Impression that the Targeted Parent is Dangerous
Strategy 9: Confiding in Child
Strategy 10: Forcing the Child to Reject the Targeted Parent
Strategy 11: Asking the Child to Spy on the Targeted Parent
Strategy 12: Asking the Child to Keep Secrets from the Targeted Parent
Strategy 13: Referring to the Targeted Parent by First Name
Strategy 14: Referring to a Stepparent as “Mom” or “Dad” and Encouraging the Child to Do the
Same
Strategy 15: Withholding Medical, Academic, and Other Important Information from Targeted
Parent/ Keeping Targeted Parent’s Name off of Medical, Academic, and Other Relevant Documents
Strategy 16: Changing the Child’s Name to Remove Association with the Targeted Parent
Strategy 17: Cultivating Dependency
Eight Manifestations of Parental Alienation Syndrome
1. A Campaign of Denigration
Alienated children are consumed with hatred for the targeted parent. They deny any positive past
experiences and reject all contact and communication. Parents who were once loved and valued
seemingly overnight become hated and feared.
2. Weak, Frivolous, and Absurd Rationalizations
When alienated children are questioned about the reasons for their intense hostility toward the targeted parent, the explanations offered are not of the magnitude that typically would lead a child to
reject a parent. These children may complain about the parents’ eating habits, food preparation, or
appearance. They may also make wild accusations that could not possibly be true.
3. Lack of Ambivalence About the Alienating Parent
Alienated children exhibit a lack of ambivalence about the alienating parent, demonstrating an
automatic, reflexive, idealized support. That parent is perceived as perfect, while the other is
perceived as wholly flawed. If an alienated child is asked to identify just one negative aspect of the
alienating parent, he or she will probably draw a complete blank. This presentation is in contrast to
the fact that most children have mixed feelings about even the best of parents and can usually talk
about each parent as having both good and bad qualities.
4. The “Independent Thinker” Phenomenon
Even though alienated children appear to be unduly influenced by the alienating parent, they will
adamantly insist that the decision to reject the targeted parent is theirs alone. They deny that their
feelings about the targeted parent are in any way influenced by the alienating parent and often
invoke the concept of free will to describe their decision.
5. Absence of Guilt About the Treatment of the Targeted Parent
Alienated children typically appear rude, ungrateful, spiteful, and cold toward the targeted parent,
and they appear to be impervious to feelings of guilt about their harsh treatment. Gratitude for gifts,
favors, or child support provided by the targeted parent is nonexistent. Children with parental
alienation syndrome will try to get whatever they can from that parent, declaring that it is owed to
them.
6. Reflexive Support for the Alienating Parent in Parental Conflict
Intact families, as well as recently separated and long-divorced couples, will have occasion for
disagreement and conflict. In all cases, the alienated child will side with the alienating parent,
regardless of how absurd or baseless that parent’s position may be. There is no willingness or
attempt to be impartial when faced with interparental conflicts. Children with parental alienation
syndrome have no interest in hearing the targeted parent’s point of view. Nothing the targeted parent
could do or say makes any difference to these children.
7. Presence of Borrowed Scenarios
Alienated children often make accusations toward the targeted parent that utilize phrases and ideas
adopted from the alienating parent. Indications that a scenario is borrowed include the use of words
or ideas that the child does not appear to understand, speaking in a scripted or robotic fashion, as
well as making accusations that cannot be supported with detail.
8. Rejection of Extended Family
Finally, the hatred of the targeted parent spreads to his or her extended family. Not only is the
targeted parent denigrated, despised, and avoided but so are his or her extended family. Formerly
beloved grandparents, aunts, uncles, and cousins are suddenly and completely avoided and
rejected.
Intake Questions
Disclaimers, Terms, and Release of Liability
By providing your phone number, other contact information, or any personally identifiable
information, for the purpose of contact with other program members within the Parental Alienation
Support Systems (PASS) program, you hereby acknowledge and agree to the following terms, in
addition to any additional terms as outlined in this document or on our website, PASS Program.org.
Voluntary Disclosure: You are willingly and voluntarily providing your contact information to be
shared with other participants in the program. You understand that this is at your own discretion and
initiative.
Release of Liability: You fully release and agree to hold harmless PASS Program , its staff,
volunteers, affiliates, and representatives from any and all liability, claims, demands, or causes of
action, arising out of or related to the sharing or use of your contact information by others in the
program.
Personal Responsibility: You acknowledge that once your contact information is shared, you
assume all responsibility for any and all communications, interactions, and any consequences
thereof. You agree that the PASS Program is not responsible for the conduct or actions of other
program participants.
Caution Advised: It is your responsibility to exercise caution, discretion, and judgment when
interacting with other participants. PASS Program cannot guarantee the actions, intentions, or
confidentiality of other individuals.
No Guarantees or Endorsements: PASS Program does not endorse or guarantee any participant’s
behavior or actions, and you understand that you are engaging with others at your own risk and
discretion.
By providing your contact information, you confirm that you have read, understood, and agreed to
the terms of this disclaimer. If you do not agree with these terms, please do not continue and do not
share your contact information.
By signing and submitting this form, you acknowledge and agree to the following:
1 Voluntary Participation: PASS Program does not endorse or guarantee any participant’s
behavior or actions, and you understand that you are engaging with others at your own risk and
discretion.
2 No Medical or Crisis Services: I understand that PASS Program and its staff, volunteers,
or affiliates do not provide medical, clinical, or emergency mental health care. Any
information, guidance, or support provided is for educational and peer-support purposes only
and should not be considered a substitute for professional diagnosis, treatment, or therapy.
3 Personal Responsibility: I am solely responsible for my own health, safety, and well-being.
I agree to seek immediate professional or emergency help if I am in crisis or believe I may
harm myself or others.
4 Release of Liability: In consideration of being permitted to participate in any program or
activity associated with PASS Program, I hereby release, discharge, and hold harmless
PASS Program, its directors, officers, employees, volunteers, and affiliates from any and all
liability, claims, demands, actions, or causes of action arising out of or related to any loss,
damage, injury, or adverse outcome that may occur as a result of my participation, under any
circumstance.
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