Citizens Commission on Human Rights

Free DVD & Information Package

Whistleblowers, 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

When did the abuse you wish to report occur?

What was the diagnosis given?

Was this given after a thorough medical examination for underlying physical problems that could look like "mental illness"?

Was there health Insurance involved?

Did it seem the diagnosis was based on what insurance coverage was coverage?

Was length of hospitalization increased or decreased based on insurance held?

Was informed, written consent given before any treatment was administered?

Was the person given a copy of his/her rights, including the right to see an attorney, when admitted or prior to any hearing to determine involuntary placement or commitment to a psychiatric facility?

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 was the last known address and phone number of the practice of this 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 where this occurred? If more than one facility, please indicate. Include the address and phone number for each facility if known:

In addition, are you interested in the following:
1. Doing media interviews on this case to alert the public to these issues?
yes no
2. Assisting in obtaining legislation in your state on issues that address the type of abuses in this case?
yes no
3. Writing letters to congressmen on these abuses?
yes no

	GET INVOLVED
	Contact Us

	Take Action

日本語 Italiano Français Deutsch Español Ελληνικά