PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM

PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM
Protect Yourself Against Misdiagnosis and Abuse

This Psychiatric Diagnosis Abuse Report Form is for your protection. You can fill out this form and provide it to your legal representative to take further action.

Anyone diagnosed with a psychiatric (mental) disorder has the right to informed consent before any treatment is undertaken. Unlike diagnoses for medical conditions, psychiatrists do not have blood tests or any other biological tests to ascertain the presence or absence of a mental illness. It is important to know that according to one state government medical manual, “Mental health professionals working within a mental health system have a professional and a legal obligation to recognize the presence of physical disease in their patients and to rule out any physical condition causing a patient’s mental disorder.”

Psychiatrists rarely conduct thorough physical examinations to rule out medical conditions, thereby misdiagnosing the patient. This can result in inappropriate and dangerous treatment, added to the fact that the real underlying medical condition is left untreated.

Further, if a psychiatrist asserts that your mental condition is caused by a “chemical imbalance” in the brain or is a neurobiological disorder, you have the right to ask for the lab test or other test to prove the accuracy of that diagnosis.

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This Psychiatric Diagnosis Abuse Report Form is for your protection. You can fill out this form and provide it to your legal representative to take further action.

NAME OF DOCTOR/PSYCHIATRIST SEEN:

NAME OF HOSPITAL, IF ANY:

ADDRESS/CONTACT INFORMATION:

DATE(S) SEEN:

REASON FOR VISIT:

1. SYMPTOMS CONVEYED TO DOCTOR:

2. HOW LONG WAS THE CONSULTATION?:

3. WHAT WAS THE DIAGNOSIS? (Provide as many specifics as given you.):

Other:

5. IF A CHEMICAL IMBALANCE WAS GIVEN AS PART OF THE DIAGNOSIS, DID YOU ASK THE DOCTOR FOR A TEST TO SUBSTANTIATE THIS? IF SO, WHAT DID HE SAY?:

6. WHAT TREATMENT WAS PRESCRIBED? (If psychiatric drug, name the drug, the dose and the reason this was recommended):

7. DID THE DOCTOR ADVISE THAT THE DRUG IS APPROVED FOR THE USE IN THE TREATMENT OF DIAGNOSIS GIVEN YOU?:

8. DID YOU EXPERIENCE ANY ADVERSE REACTION FROM THE TREATMENT? (Provide details, including how long you were on the drug.):

9. WAS THERE ANY IMMEDIATE OR LONGER TERM PHYSICAL OR MENTAL CONDITION OR DAMAGE AS ARESULT OF THE TREATMENT? (Provide details):

10. DID YOU LATER ESTABLISH THAT THERE WAS A MEDICAL CONDITION THE PSYCHIATRIST OR DOCTOR DID NOT DIAGNOSE OR IDENTIFY BEFORE GIVING THE PSYCHIATRIC DIAGNOSIS? If so, please provide specifics and if that condition was diagnosed by another physician who conducted appropriate tests.:

11. DO YOU NEED ASSISTANCE FROM CCHR TO TAKE ACTION? (If so, see contact information below.) :

12. Is CCHR authorized to share this form with agents, consultants, representatives or attorney?:

SIGNED :

DATE :

Your Name:

Address:

Phone:

Email: *

Provide a copy of this form to your attorney, another to your insurance carrier and/or government insurance. If you are currently in the military, provide a copy to your chaplain and legal representative. Also submit this form to CCHR. In this way, we can assist you in taking any further action.

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FAX: 1-323-467-3720
E-mail: contact@cchr.org

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