PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM

PROTECT YOURSELF AGAINST PSYCHIATRIC ABUSE

This Psychiatric Diagnosis Abuse Report Form is for your protection. You can fill out this form and provide it to your legal representative to take further action. While not all information is required to submit your report, please provide as much information as possible.

INFORMATION ON THE PERSON ABUSED:

NAME:

Last Name

Age of Abused

ADDRESS:

Street Address

City

Country

State/Province

Postal Code

CONTACT INFO:

Email Address

Phone Number

ARE YOU THE PERSON WHO WAS ABUSED?

Yes

DETAILS ABOUT THE ABUSE:

When, approximately, did the abuse occur?

When, approximately, did the abuse end?

SUMMARY OF ABUSE THAT OCCURRED:

(Please do not mention any information relating to criminal convictions and offenses allowing specific persons to be identified.)

WERE PSYCHIATRIC DRUGS PRESCRIBED?

Yes

FACILITIES WHERE THE ABUSE OCCURRED:

NAME:

Type of Facility

If other, please specify

Facility Name

FACILITY ADDRESS:

Street Address

City

Country

Postal Code

State/Province

Phone Number

Add another facility

DOCTORS WHO WERE INVOLVED WITH THE ABUSE:

DOCTOR’S NAME:

Doctor's First Name

Doctor's Last Name

Choose a type of Doctor

DOCTOR’S ADDRESS:

Street Address

Apartment/Suite/Room, etc.

City

Country

Postal Code

State/Province

Phone Number

Add another doctor

ADDITIONAL INFORMATION:

ARE YOU WORKING WITH AN ATTORNEY?

Yes

WOULD YOU LIKE ASSISTANCE IN GETTING AN ATTORNEY TO FILE CHARGES OR REPRESENT YOUR CASE?

Yes

WHAT ACTIONS ARE YOU INTERESTED IN TAKING ON THIS CASE?

Having CCHR further investigate this case.

Having complaints filed on your/another’s behalf (with their permission) with the proper authorities.

Speaking out in media/social media.

Assisting in obtaining legislation in your state on issues that address the type of abuses in this case.

Starting or getting involved in a support group for people who have suffered similar abuses.

Other

PREFERRED CONTACT:

Best time to contact you?

Best way to contact you?

Consent for processing personal data – I consent to the processing of my personal data by CCHR under the controllership of the Church of Scientology International, 6331 Hollywood Boulevard, Los Angeles, CA 90028, United States of America, to perform the actions indicated on this Abuse Report Form. By providing CCHR with personal data about third parties (such as abused persons or doctors or attorneys), I acknowledge that I am fully responsible for sharing this personal data with CCHR and warrant that I have obtained the third party’s freely given, specific and informed consent to perform the actions indicated on this Abuse Report Form. If a third party withdraws his or her consent, I will immediately inform CCHR by sending an email to privacy@cchr.org.

Explicit consent for sensitive personal data – I consent to the processing of my sensitive personal data by CCHR under the controllership of the Church of Scientology International, 6331 Hollywood Boulevard, Los Angeles, CA 90028, United States of America, to perform the actions indicated on this Abuse Report Form. By providing CCHR with personal data about third parties (such as abused persons or doctors or attorneys), I acknowledge that I am fully responsible for sharing this sensitive personal data with CCHR and warrant that I have obtained the third party’s freely given, specific, informed and explicit consent to perform the actions indicated on this Abuse Report Form. If a third party withdraws his or her consent, I will immediately inform CCHR by sending an email to privacy@cchr.org.

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