You can either complete this form online or fill out a printed copy and send it to our office at the following address:
P.O. Box 11284
Eugene, OR 97440 USA
Please feel free to contact us at firstname.lastname@example.org if you have any questions or require any assistance pertaining to the form and/or the submission process.
Once your submission has been processed, your email address will be added to our Shield alert mailing list, allowing you to receive notifications about ongoing Shield campaigns.
Online Registration Form
I hereby declare and direct that, unless specifically agreed to by me, I refuse to be forced to undergo any psychiatric procedure(s) including:
- the administration of psychotropic drugs;
- the administration of any other drugs used for psychiatric purposes;
- the administration of electroconvulsive therapy (ECT or "electroshock");
- the administration of any form of psychosurgery;
- 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);
- the administration of any type of implant or stimulus device(s) used for a psychiatric purpose;
- the administration of any restraint device or solitary confinement;
- the administration of any aversive therapy or behavior modification;
- detention in a psychiatric facility or any other facility for a psychiatric reason, or
- any combination thereof.
Unwanted Psychiatric Intervention
Should I be threatened with or subjected to any Unwanted Psychiatric Intervention, I may request that the MindFreedom Shield Program issue a Human Rights Alert on my behalf.
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(es) with which I have been labeled, 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).