Psychiatric / Wellbeing Abuse Form
Report as much detail as you can. * indicates a required field.
City / Suburb
Australia Capital Territory
Name of person who was subjected to the abuse (if not you)
Names & Professions of Involved Personnel*
What facility did the abuse occur in and what type of facility was it?*
Date the abuse began:
What was happening with the child/children/you/person at the time the incident started? (be sure to include any physical illness, problems in life etc. )*
Were you, or the person/persons involved, seen by a mental health practitioner? If so, when? What was the result?*
Were psychiatric drugs given and, if so, in what dosages?*
Were you (or the person or persons involved) involuntarily detained, given electroshock treatment, restrained, secluded? What happened and what were the results of these treatments?*
Were you or your family or child(ren) threatened or otherwise coerced to go along with any treatments, evaluations etc?*
What were the results of what happened to you and/or your family or child(ren)?*
Have you contacted a lawyer? If yes, what was the outcome*
Have you filed any complaints on this abuse? If yes, with what organisation or official and when was the complaint filed?*
Any other information that you would like to tell us, or feel is important to the case?
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