MindFreedom Shield Registration Form
To register your MindFreedom Shield please read and complete this form and click the Submit button near the bottom. Please make sure all of the information is correct before it is submitted. Your membership needs to be current. If you have any questions or need assistance completing this form, please contact the MindFreedom office before submitting it. You are required to fill out the fields with a mark next to them. Other fields are optional. When your “Shield” is processed, if you have an e-mail address you will be added to the “Solidaritynet” list to get notifications of activated Shields.
I hereby declare and direct that, unless specifically agreed to by me, I refuse to be subjected to any psychiatric procedures(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).
By clicking the above submit button for the MindFreedom Shield Registration Form, I acknowledge and agree that:
- I have read, voluntarily completed and understand all of the contents of this MindFreedom Shield Registration Form.
- I agree to take responsibility to notify MindFreedom in writing if any information related to this MindFreedom Shield changes.
- This MindFreedom Shield will remain in effect as long as my MindFreedom membership is current, or until revoked in writing by me, or until MindFreedom, at its discretion, alters or ends the MindFreedom Shield Program.
- I further understand MindFreedom reserves the right to decide at its discretion whether or not to issue a Human Rights Alert, which may include notifying the media; that MindFreedom generally words Human Rights Alerts as allegations made by an individual against licensed professionals or facilities; that MindFreedom cannot guarantee results once an alert has been issued and that I may be subjected to Unwanted Psychiatric Intervention, including retaliation, even after this MindFreedom Shield is registered or after a Human Rights Alert has been issued on my behalf.
- I further understand that when notified about an Unwanted Psychiatric Intervention the MindFreedom Shield may issue only one (1) Human Rights Alert and nothing more, and that MindFreedom International is not agreeing to provide legal advocacy, advice or services.
- I further understand that the MindFreedom Shield is not meant to replace a formal psychiatric advance directive or other similar legal document, and that it is highly recommend that I obtain an advance directive if I have not already.
- I affirm that to the best of my ability any and all information I provide to MindFreedom regarding my MindFreedom Shield is at all times accurate and true, and that I accept full responsibility for any erroneous or inaccurate information that I may provide.
- I agree to not hold MindFreedom or any of its staff, Sponsor Organizations, affiliates, members, volunteers, or board of directors civilly or criminally liable for any injury, damages or loss I may sustain, foreseeable or not, as a result of establishing or activating my MindFreedom Shield and the issuance of a Human Rights Alert(s), including any inaccuracies or errors in any alert. This also applies to the person(s) I have listed above as a contact person.
- I agree to participate in the MindFreedom Solidarity Network nonviolently and in a spirit of mutual cooperation to the best of my ability including whenever MindFreedom issues a Human Rights Alert regarding another Shield registrant.
- I recognize that any information about me involving the MindFreedom Shield that is made public — such as (though not limited to) the MindFreedom Shield Public Registry or any Human Rights Alert — may become accessible to others, such as on the Internet, in perpetuity, and that it may not be possible or practical to recall, retract, modify or make this information private in the future.
- If I have any questions about this form, I will contact the MindFreedom office before submitting it.
I agree with the above terms of the MindFreedom Shield Registration.