Citizens Commission on Human Rights

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Report Psychiatric Abuses

Thank you very much for your report.

Name: (yours and anyone else involved - i.e. Your child, family member etc.)
*First Name:	*Last Name:

Anyone else involved:

*Address:

*City:

*State/providence:	*Zip/postal code:

*Country:

Phone: *Home:	Work:

Other:	E-mail:

*Birth Date:

* and bold means a required field

YOUR REPORT

Questions to be answered as fully as possible (Please give specific dates if possible.).

When did the abuse you wish to report occur?

Who was the treating doctor on the case? Please write in full: name and what kind of a doctor they are: i.e. psychiatrist, psychologist, etc.

What are the names of any other staff or doctors that you feel were involved in the abuses? (Please state what their position [ job] was.)

What is the name of the hospital/facility that this occu rred in? If more than one facility, please indicate. Include the address and phone number for each facility if known:

What was the last known address and phone number of the practice of this psychiatrist, psycholo gist, etc.?

If the injured party is/was insured (private or government or social security medical coverage), what is the name of the insurance company or benefits that paid for your treatment and/or hospitalization?

What was the reason you were placed under the care of a psychiatrist in this facility? (Please differentiate what the psychiatrist diagnosed or said you were suffering from, and what you feel was the problem [if any] at the time.)

Did you admit yourself voluntarily?

yes no

Were you admitted involuntarily (against your will)?

yes no

Were there any court orders involved in your situation?

yes no

if yes, who requested them?

For what reason?

Were you informed of your rights as a patient before admission? If not before admission, at any time during your admission?

yes no

If yes, who informed you and what were you told?

Did any of the following occur to you? (if yes, please give specifics.)

yes no

Drugged Without Permission?

yes no

If yes, what drugs were you given? (include dosages & how often they were given)

Over drugged?

yes no

Any side effects from the drugs that were intolerable?

yes no

If yes, what were these side effects?

Permanent or persisting effects of the drugs?

yes no

If yes, what were these effects and are you still affected by them?

Informed about drug side-effects?

yes no

(If you were informed, please specify what you were told.)

Sexual abuse, misconduct or rape?

yes no

(If this did occur, it may be difficult to report the details, but please write what you can and who was involved in this abuse.)

Was this sexual abuse called therapy?

yes no

If yes, by whom?

Use of restraints?

yes no

If placed in restraints and/or isolation were you checked on regularly?

yes no

If so, how often?

Were you ever threatened with physical harm?

yes no

If yes, by whom? Was there any reason the threat was made?

Were you threatened with committal or punishment if you refused to accept the psychiatric treatment given to you?

yes no

If yes, by whom and what happened?

Were you coerced into hospitalization or treatment?

yes no

If yes, by whom and how?

Were you given electroshock? (also known as electric shock treatment, electroconvulsive therapy, shock treatment, etc.)

yes no

If yes, what were you told about the electroshock treatment prior to its administration?

Did you sign any form giving consent to the electroshock?

yes no

If yes, what did the form say?

Was your insurance completely used up?

yes no

How much was used?

Do you have copies of the insurance billings and medical records?

yes no

Were there any charges for services you didn't receive?

yes no

Any double billing on your insurance?

yes no

Any outrageous charges on your insurance bills?

yes no

Did you witness any of the above done to others?

yes no

If yes, and you have the information, please state names, what was done and who committed the abuse:

What was the reason given for discharging you?

Have you contacted an attorney?

yes no

What was his or her response to the case? (this does not affect our interest in the case.)

Have you filed any complaints on this/these abuse(s)?

yes no

If yes, with what organization or official?

When was the complaint filed?

In addition, are you interested in the following:

	1. Having CCHR further investigate this case.
	2. Having complaints filed on your/another's (with their permission) behalf with the proper authorities.
	3. Doing media interviews on your case to alert the public to these issues.
	4. Assisting in obtaining legislation in your state on issues that address the type of abuses in your or another's case.
	5. Writing letters to congress on these abuses.
	6. Starting or getting involved in a support group for people who have suffered similar abuses.

Thank you for submitting this form. Someone from our office will contact you to assist you with the next steps to take on your case, once this information has been reviewed and it has been determined what we can best do to help expose and correct what has been done to you.

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