Abuse Report Form

PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM

PROTECT YOURSELF AGAINST PSYCHIATRIC ABUSE

This form is designed to protect your rights. You may complete it and share it with your legal representative to support further action. While not every field is required, please provide as much detail as you feel comfortable supplying to help us process your report effectively.

CCHR Africa: Report Form

INFORMATION ON THE PERSON ABUSED:

DETAILS ABOUT THE ABUSE:

TYPE OF ABUSE THAT OCCURRED:

FACILITIES WHERE THE ABUSE OCCURRED:

DOCTORS WHO WERE INVOLVED WITH THE ABUSE:

ADDITIONAL INFORMATION:

PREFERRED CONTACT: