1. Applicant’s declaration against unwanted psychiatric intervention

I hereby declare and direct that, unless specifically agreed to by me, I refuse to be subjected to any psychiatric procedures(s) including:

  1. the administration of psychotropic drugs;
  2. the administration of any other drugs used for psychiatric purposes;
  3. the administration of electroconvulsive therapy (ECT or “electroshock”);
  4. the administration of any form of psychosurgery;
  5. the administration of any brain altering technology for a psychiatric purpose including (but not limited to) vagus nerve stimulation and repetitive transcranial magnetic stimulation (rTMS);
  6. the administration of any type of implant or stimulus device(s) used for a psychiatric purpose;
  7. the administration of any restraint device or solitary confinement;
  8. the administration of any aversive therapy or behavior modification;
  9. detention in a psychiatric facility or any other facility for a psychiatric reason, or
  10.  any combination thereof.

Should I be threatened with or subjected to any unwanted psychiatric intervention, I may request that MindFreedom International (MFI) issue a human rights alert on my behalf through its Shield Program.

I understand and desire that such an alert may be made public and understand it may contain personal information, including (but not necessarily limited to) my name, location, psychiatric diagnosis, the unwanted psychiatric intervention to which I may be or am being subjected, where/how such procedure(s) may be/are taking place, and who is threatening or administering these procedure(s).


2. Applicant information and agreement to the Shield Program’s terms