Damaged by Electroconvulsive therapy (ECT)? Tell your story here

If you have received ECT and experienced ill-effects, or know someone who has, please fill in the form below. Your information is very important to us.

Introduction

Did you receive ECT?
YesNo

Details of the person who received ECT

First Name *
Last Name *
Email *
Telephone
Town/City
Gender
MaleFemale
Age

If you are reporting on behalf of someone else please fill in this section

Your name
Your email
Your telephone
Your relationship to the person you are reporting about

Details of the treatment

When was ECT given?
Approximately how many times was ECT given?
Was consent given for the treatment? *
YesNoDon't know/don't remember
Please describe what happened
Please list any short-term effects of the treatment
Please list any long-term effects of the treatment

Hospital and Psychiatrists involved

Hospital name where ECT was performed
Name of doctor #1
Name of doctor #2
Any other information you would like to give?

Privacy

Please tick the relevant box(es)
Your information is kept strictly confidential and will only be used with your permission.I hereby authorise the Citizens Commission on Human Rights (CCHR) to conduct an investigation into this caseOR: I do not wish any action to be taken. The details of my treatment are being sent as information only.

Spam check

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