Thank you for telling your disconnection story. In addition to the specific questions, there is space for any additional comments you wish to make at the end.
Please note: this site is about intentional disconnections. It is not intended to cover stories of people who drifted apart, moved away and lost touch, or other such dissolutions of a relationship. It is intended to cover only scientology-related disconnections that were deliberate.
A real name is not necessary unless you are comfortable with leaving it, otherwise, please make up an alias. However, in the case that you would like to reconnect with the person, leaving a real name or a nickname that your disconnected person would recognize, if they should happen upon this site, will let them know your feelings on this matter.
The required fields are "Name or Alias," "Membership status?, "Which one of you disconnected?, and "Additional comments." All other questions are voluntary.
There is a place for contact information; what you put here will not appear on the site, and is not a required field. I am interested in helping any disconnected people who wish to reconnect to do so, provided both are willing. Read more about why and how this will work.
If you have ever been a member of the Church of Scientology, please consider answering the interview questions at Scientology - Through the Door.
WARNING: If you have reason to maintain your anonymity, whether it be family or friends in the Church of Scientology, fear of retribution or Black PR, or anything else, please take care to leave out personal details which could be pieced together by OSA to determine your identity.