CCHR-Victoria

Psychiatric / Wellbeing Abuse Form

Report as much detail as you can. * indicates a required field.

First name

Last name

Email address

Mobile

Street address

City / Suburb

State

Postcode

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?