Please fill in the form below to report psychiatric abuse. The form is quite extensive so please give as much information as you can. All information will be kept in strict confidence unless your permission is given to release it. After this form has been reviewed, a representative from CCHR will be contacting you either by phone or letter to acknowledge receipt and inform you of the next steps to be taken on your case.

Name: Address:   Telephone: Email: Are you the abused person? yes no If no, what is your relationship to the abused person? Date of Birth (of the abused): When did the abuse you wish to report occur? What abuse would you like to report? What are the names of the psychiatrists, psychologists and/or psychiatric facility involved? What was the reason you/the abused 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) Were you/the abused admitted voluntarily? yes no Were you/the abused admitted involuntarily (against your will)? yes no Were there any court orders involved in the situation? yes no if yes, who requested them? For what reason? Were you/the abused 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/the abused? (if yes, please give specifics) Physical abuse? 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/the abused coerced into hospitalization or treatment? yes no If yes, by whom and how? Were you/the absued given electroshock? (also known as electric shock treatment, electroconvulsive therapy, shock treatment, etc.) yes no If yes, what were you/the abused told about the electroshock treatment prior to its administration? Did you/the abused 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/the abused? Have you contacted a solicitor? yes no What was his or her response to the case? (this does not affect CCHR's interest in the case.) Have you/the abused filed any complaints on this/these abuse(s)? yes no If yes, with what organization or official? When was the complaint filed? Post this form to: Citizens Commission on Human Rights P.O. Box 188 East Grinstead West Sussex RH19 4RB