Citizens Commission on Human Rights, CCHR: Take Action, Get Involved in The Fight For Human Rights.

First Name

Middle Name

Last Name

Street Address

Apartment/Suite/Room, etc.

City

Country

Postal Code

State/Province

Age of Abused

Approximate Date Abuse Occurred

Approximate Date Abuse Ended

Email Address

Phone Number

Relation to the Abused Person

If other, please explain

First Name

Middle Name

Last Name

Street Address

Apartment/Suite/Room, etc.

City

Country

Postal Code

State/Province

Email Address

Phone Number

#1—Facility Type

If other, please explain

Facility Name

Street Address

City

Country

Postal Code

State/Province

Phone Number

#2—Facility Type

If other, please explain

Facility Name

Street Address

City

Country

Postal Code

State/Province

Phone Number

#1—Doctor First Name

#1—Doctor Last Name

#1—Doctor Type

Street Address

City

Country

Postal Code

State/Province

Phone Number

#2—Doctor First Name

#2—Doctor Last Name

#2—Doctor Type

Street Address

City

Country

Postal Code

State/Province

Phone Number

How long were the drugs taken for?

What dosage was prescribed?

Are you/they still taking psychiatric drugs?

Attorney Name

Street Address

City

Country

Postal Code

State/Province

Phone Number

Email Address

Current Status of Case

Would Like Assistance in Getting an Attorney to File Charges or Represent Your Case?

Having complaints filed on your/another's (with their permission) behalf with the proper authorities.

Assisting in obtaining legislation in your state on issues that address the type of abuses in this case.

Starting or getting involved in a support group for people who have suffered similar abuses.

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PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM
Protect Yourself Against Psychiatric Abuse

Information on the person abused:

Information on the person reporting the abuse (if different than above):

Facilities where the abuse occurred:

Doctors who were involved with the abuse:

Were psychiatric drugs prescribed?

Are you working with an attorney?

Would Like Assistance in Getting an Attorney to File Charges or Represent Your Case?

What actions are you interested in taking on this case?

Preferred contact

International Sites

Links

PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM Protect Yourself Against Psychiatric Abuse

Information on the person abused:

Information on the person reporting the abuse (if different than above):

Facilities where the abuse occurred:

Doctors who were involved with the abuse:

Were psychiatric drugs prescribed?

Are you working with an attorney?

Would Like Assistance in Getting an Attorney to File Charges or Represent Your Case?

What actions are you interested in taking on this case?

Preferred contact

International Sites

Links

PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM
Protect Yourself Against Psychiatric Abuse