Citizens Commission on Human Rights

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Parents and Grandparents, Report Psychiatric Abuses

Thank you very much for your report.

YOUR INFORMATION

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: *
	(mm/dd/yyyy)
How did you hear about us?

* and bold means a required field

YOUR REPORT

Names of any school/mental health personnel involved:
(be sure to include the person's profession - e.g., school psychologist, social worker, etc.)

Describe the abuse that occurred and include all dates:

What was happening with the child/children/family member immediately prior to or at the time the incident/abuse started (be sure to include any physical illness, problems in life etc.)

Was the child seen by a mental health practitioner, school psychologist, or psychiatrist? When? What was the result?

Were you or your family or child(ren) threatened or otherwise coerced to accept any psychiatric or psychological treatments, evaluations, etc.? If so, what happened?

Did you place your child(ren) on psychiatric "medication," such as stimulants? Did the child(ren) suffer any side effects? If so, what was the medication and its side effects that you noticed?

Any other information that you would like to tell us, or feel is important to the case?

Your Name:

Today's date:

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 this 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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