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All information will be kept in strict confidence unless your permission is given to release it. After this form has been reviewed, a representative from CCHR will be contacting you either by phone or letter to acknowledge receipt and inform you of the next steps to be taken.

* Please make sure you include contact details ie email address, telephone.

* Name:

Address:

* Telephone:

* Email:

Date of Birth:

1. Are you the abused person?

Yes

No

1a. If no, what is your relationship to the abused person?

2. What abuse would you like to report?

3. What are the names of the psychiatrists, psychologists and/or psychiatric facility involved?

4. Was the abused person administered drugs, electroshock or any other "therapy"? How often or how much?

5. Was the abused person put into restraints, seclusion or threatened with physical harm? If so, what happened?

6. Has the victim been discharged? If so, what was the reason given?

7. Have you or the victim contacted a lawyer? If yes, whom?

8. Have you or the victim filed any complaints on these abuses? If yes, with what agencies or organisations?

CCHR, CITIZENS COMMISSION ON HUMAN RIGHTS and its logo are trademarks and service marks owned by Citizens Commission on Human Rights.
© 2007 Citizens Commission on Human Rights (United Kingdom). A company limited by guarantee. Company Reg No. 4085083. Citizens Commission on Human Rights,
CCHR and the CCHR logo are trademarks and service marks owned by Citizens Commission on Human Rights and are used with its permission.