Citizens Commission on Human Rights, CCHR: Take Action, Get Involved in The Fight For Human Rights.

First Name

Middle 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?

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?

Name of drug(s) prescribed:

How long were the drugs taken for?

What dosage was prescribed?

ARE YOU/THEY STILL TAKING PSYCHIATRIC DRUGS?

FACILITIES WHERE THE ABUSE OCCURRED:

FACILITY TYPE:

Type of Facility

If other, please specify

Facility Name

FACILITY ADDRESS:

Street Address

City

Country

Postal Code

State/Province

Phone Number

DOCTORS WHO WERE INVOLVED WITH THE ABUSE:

DOCTOR’S NAME:

DOCTOR’S ADDRESS:

Street Address

Apartment/Suite/Room, etc.

City

Country

Postal Code

State/Province

Phone Number

ADDITIONAL INFORMATION:

ARE YOU WORKING WITH AN ATTORNEY?

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

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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PSYCHIATRIC DIAGNOSIS ABUSE REPORT FORM

INFORMATION ON THE PERSON ABUSED:

INFORMATION ON THE PERSON REPORTING THE ABUSE:

DETAILS ABOUT THE ABUSE:

WERE PSYCHIATRIC DRUGS PRESCRIBED?

FACILITIES WHERE THE ABUSE OCCURRED:

DOCTORS WHO WERE INVOLVED WITH THE ABUSE:

ADDITIONAL INFORMATION:

PREFERRED CONTACT:

International Sites

Links