Anyone else involved
Street & Number
2nd Contact Phone
Names & Professions of Involved Personnel
What facility did the abuse occur in and what type of facility was it?
Date this 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. )
Was the person/persons involved or you seen by a mental health practitioner? If so, when? What was the result?
A. What psychiatric drugs were you given and in what dosages?
B. Were you 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)?
Do you have your or the person’s medical records?
Have you contacted a lawyer?
Have you filed any complaints on this abuse?YesNo
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?