Surgical Clarity Division Intake Form

SECTION 1: BASIC INFO (Required)

Full Name

Preferred Name (if different)

Email Address

Phone Number (optional)

Date of Birth

State and Country of Residence (for jurisdictional routing)

Do you wish to remain anonymous in generated reports?

Yes
No

SECTION 2: SURGICAL CONTEXT (Required)

What type of surgery did you receive?

Date of your surgery (if known)

Surgical location/facility

Name of the primary surgeon (if known)

Was this your first surgery on this body part?

Yes
No

Were you prescribed pain medication post-operatively?

Yes
No
Not Sure

Were you given a brace or assistive device?

Yes
No

If Yes: What were the usage instructions?

Did you raise concerns about pain, swelling, or instability?

Yes
No

If Yes: How were those concerns addressed?

SECTION 3: EXPERIENCE & TRAUMA MAPPING (Required)

When did you first feel something was wrong?

Describe what made you feel that way.

Did any medical professional dismiss or minimize your concerns?

Yes
No

If Yes: Who, and what did they say?

Did you feel pressured to accept that your symptoms were “normal”?

Yes
No
Not Sure

How long did you continue to experience symptoms before they were taken seriously?

SECTION 4: OPIOID VULNERABILITY & PAIN MANAGEMENT

Did your unmanaged pain lead to thoughts of seeking painkillers outside the system?

Yes
No
Prefer not to say

Did you consider fabricating symptoms to access medication?

Yes
No

Were you eventually prescribed pain relief by another provider?

Yes
No
Still untreated

Did you consider self-harm, substance use, or illegal drugs to escape the pain?

Yes
No
Prefer not to say

Did you experience symptoms of emotional collapse (e.g., insomnia, anxiety, panic, dissociation)?

Yes
No

Optional: Describe what you experienced.

SECTION 5: CURRENT STATUS (Required)

Have you had a revision surgery or second opinion?

Yes
No
Scheduled
Refused

Has your original surgeon acknowledged any failure or error?

Yes
No
Implicity
Not Applicable

Do you believe your original surgery was botched?

Yes
No
Unclear

Are you currently pursuing legal action or considering it?

Yes
No
Not Sure

SECTION 6: SERVICE REQUEST (Required)

Which services do you want us to provide? (Check all that apply)

Formal Medical Board Complaint Letter
Hospital Ethics Complaint Letter
Licensing Body Complaint Letter
Surgical Harm & Trauma Assessment Report
Insurance Appeal or Grievance Letter
Recovery Intelligence Output (personalized pacing + advocacy guide)
Public Testimony Statement (optional)

Do you want your documents to be anonymized?

Yes
No

Do you want us to use the surgeon’s name in formal complaints?

Yes
No
Redacted

SECTION 7: DOCUMENTS (Optional but Strongly Encouraged)

Upload any of the following (optional):

Operative report (PDF, DOC)
Post-op instructions
Communications (emails, notes, messages)
Insurance denial letters
Photos of swelling, instability, or brace use

Note: Select any documents, photos, and notes upload the files. (supported files: jpg, jpeg, png, gif, webp, bmp, svg, tiff, doc, docx, xls, xlsx, ppt, pptx, txt, rtf, csv, odt, ods, odp, pdf)

Click here to upload

Choose files

SECTION 8: YOUR VOICE (Optional)

Use this space to say anything else that matters.

Consent Checkbox

I understand that The Resilience Project provides non-legal, trauma-informed support services. I consent to have my inputs reviewed by a trained human team and processed into written documents