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| ABUSE
CASE INVESTIGATION FORM |
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Hello,
Thank you for contacting the Citizens
Commission on Human Rights. Your response is very much appreciated.
Without the courage and help of people like you, we would never have
been able to make the headway we have in the fight against human rights
violations so prevalent in the psychiatric system. The first step to
correcting injustices and human rights abuses is to report them because
something can be done about any situation. Your rights can be upheld,
as our organization has shown over and over again. All information will
be kept in strict confidence unless your permission is given to release
it.
To help us assist you, please fill out this
questionnaire as fully as possible. If there are further details that
you want to make known, please fill out the optional area for
additional comments below.
After this form has been reviewed, a
representative from our office will be contacting you either by phone,
email or letter to acknowledge receipt of this information and inform
you of the next steps to be taken on your case.
Please note that CCHR does not give medical or
legal advice.
(All items marked with a red
asterisk are required to fill out.) |
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| *Name: |
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| *Address: |
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| *Phone: |
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| *Email: |
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*ID (such as a
driver's license or
social security number): |
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| Please answer all questions as fully as possible. |
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| If no, what is your relationship
to abused person? |
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| 2. What abuse would you like to report? |
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| 3. What are the names of the psychiatrists, psychologists
and/or psychiatric facility involved? |
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| 4. Was the abused person administered drugs, electroshock
or any other "therapy"? |
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| How often or how much? |
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| 5. Was the abused person put into restraints, seclusion
or threatened with physical harm? |
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| If so, what happened? |
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| 6. Has the victim been discharged? If so, what was the
reason given? |
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| 7. Have you or the victim contacted an attorney? If yes,
whom? |
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| 8. Have you or the victim filed any complaints on these
abuses? |
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| If yes, with what agencies or
organizations? |
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| 9. If you have any additional comments, please enter them
below. |
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