Contact CCHR UK: 01342 313926

Report Form

Wed, 07/04/2010 - 22:10 |

admin

If you or someone you know are suffering in some way, please help us by completing this questionnaire.

At CCHR we are dedicated to stopping the abuse of anyone, but especially people who do not know what is happening to them, those who are prescribed lethal drugs without knowing and understanding the consequences and side effects, those who are abused in the care of others, either mentally or physical, or in the extreme those who have undergone brain surgery or electric shock therapy to ‘cure’ them. We are interested in learning of everyone’s experiences of the mental treatments that they have received whether you are the patient or if the patient is an elderly relative, child, or other dependent.

We will keep any personal details that you give to us in complete confidence, but may use some of the details to make further enquiries and or contact you again or collect statistics on what you tell us. Click here to see our confidentiality promise to you

Who has suffered - Have you been a patient yourself or are you reporting details to us of someone else’s treatment:

If it is someone else:

i.e How do you know this person - i.e. "A Friend's child" etc.

If Drugs – what drug was originally prescribed:

How long did the first consultation last: minutes (approximately)

Details: -:

Were you/the patient given details of the side effects:

Yes

Was the patient given a physical examination and any abnormalities seen that needed treatment:

Yes

Were you/the patient treated in the following ways:

Restrained against your will

Electro-shock treatment

Abused during restraint or drugging

What other tests were carried out:

Were the results explained:

Yes

What alternatives were discussed with you at the time of the Consultation:

Other alternatives discussed:

How happy were you with the outcomes/results:

Please give further details below:

How did you feel and/or why?:

Do you/the patient feel that you/they need further help?:

Yes

Most people after mental trauma of various sorts will recover after a short time, or following other events; but we are also aware that others do need further help - indeed everyone needs such help from time to time. See the 'Alternatives' section on our website after completing this form for further details.

Do you feel that any laws have been broken or any moral issues involved:

Yes

Please provide further details below: -

Details: -:

Was anybody prosecuted?:

Yes

Who was prosecuted or is under investigation:

Please provide details of individuals and names/addresses. It is likely that we will want to contact you for further details when you complete this field so please remember to leave your own details below.

Is there someone that you can talk to about this:

Yes

Who have you been able to talk to?:

Would you like to receive further details or updates about CCHR:

Yes

e-mail address:

Please provide us with your address details:

Name:

Please type YOUR name here

The name of who you are reporting details to us about (if not yourself)::

Please ensure that this person understands that you have provided their details to us.

Would you agree to allow us to contact you to find out more or ask for more detail: *

Agreed

Not Agreed

Is there anything else that we can help you with:

Would you particularly like us to contact you:

Yes

Not sure

Other contact details:

Please give details of anyone who you think we should investigate further: