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. 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.

 

You can fill out the application on line here or, if you prefer, you can print out the form (link to PDF) and send it to:

MindFreedom International
454 Willamette, Suite 216
Eurgene, OR 97440-3484

 

MindFreedom Shield 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:

 

  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.

 

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).

  • Private Registration Information
    Whatever you checked above, the BELOW information you provide MindFreedom will remain PRIVATE unless you ask us to release it in the future.
  • Date Format: MM slash DD slash YYYY
    For more information about advanced directives, visit the Bazelon Center
  • After submitting your Shield application online, it will be reviewed by the MindFreedom office staff. If it is accepted, you will be added as a Shield participant.