Citizens Commission on Human Rights

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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: *

Address: *

City: *

State/providence: *

Zip/postal code: *

Country: *

Phone: Home: *

Work:

Other:

E-mail: *

Birth Date: *

(mm/dd/yyyy)

* and bold means a required field

	Dates of Use (Approximation if necessary)
	From	To
1
2

Adverse Result of Psychiatric Drug (Check all that apply)
Death Life-threatening Disability or Permanent Damage Birth Defect	Physical Side Effect Hospitalization Emotional/Mental Side Effect

Please Describe Reaction
(Leave field blank if not applicable)

Medical/Physical Reaction(s):

Mental/Emotional Reaction(s):

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