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Dr. Silverman Questionnaire

Did you go for an evaluation with Dr Silverman as a result of one of the following?

(check ALL that apply)

By order of Family Court (i.e. custody, paternity, support or Order of Protection)

Voluntarily at recommendation of CPS or DSS (example: Child Protective Worker asked if you would be willing to be evaluated by Dr Silverman so that your case can be closed.)

What county were you evaluated by Dr. Silverman in? (Check all that Apply)

Schoharie County

Otsego County

Oswego County

Greene County

Montgomery County

Other

During your evaluation with Dr. Silverman, were you alone with him?

Yes, I was alone with Dr. Silverman

No, I brought someone with me

While being evaluated by Dr Silverman, did he do any of the following things?

(check ALL that apply)

Being Yelled/Screamed at

Cursing/bad language used

Intimidation

Threats/Threatening language

Degrading language, or “put downs”

Interruptions when speaking

Refusal to accept your answers

Repeated questions

Insisting that you said something you didn’t

Manipulation

making false statements

Refusal to listen to differing opinion

Misconstrue/Twists your words in his report

Refusal to cooperate with requests to speak with current clinician or mental health provider

Refusal to allow you to have a copy of his report.

Other Unprofessional Conduct:

Did you receive a copy of the report generated by Dr. Silverman after his evaluation of you?

Yes

No

not sure

Did you try to get a copy of the report generated by Dr. Silverman?

Yes

No

If answered YES, I tried to get a copy, who did you ask? (please check all that apply )

My court appointed Attorney

My child’s Law Guardian

My privately retained Attorney

My Caseworker (DSS/CPS)

Dr Steven Silverman himself

Other

NA

Did you record your interaction with Dr Silverman?

Yes

No

How many times, and on what dates were you evaluated by Dr. Silverman?

What is your gender?

Male

Female

Other

Did the other party in family court have an evaluation by Dr Silverman? (i.e. spouse, other parent, ex-husband)

Yes

No

NA

Any additional comments about your experience during an evaluation by Dr. Steven Silverman

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