MindFreedom Shield Registration Form

Please complete this form and follow the link at the bottom. On the next screen, you will be presented with a personalized, printable version which you must sign, date, and send to the MindFreedom office at the address provided by postal mail. Please do not e-mail a completed form. Please note that forms submitted by e-mail or forms lacking necessary information such as dated signature(s) will not be registered. If you have any questions about this form or need assistance completing it, please contact the MindFreedom office at (541) 345-9106 or office@mindfreedom.org.

Legal name:
Street Address:
City:
State:
Zip Code:
Email Address:
Date of Birth (month, date, year):

Phone Number(s)
(Please be sure to include area code)

Do you want your name and location (city, state) listed in the public MindFreedom Shield Registry?
(please check yes or no -- if yes, please initial and date form here)

MindFreedom Shield

I, , declare that I do not want to be subjected to any coerced or forced psychiatric treatment including but not limited to the following: the administration of psychotropic drugs; the administration of any other drugs used for psychiatric purposes; the administration of electro-convulsive therapy (ECT or "shock therapy/treatment"); the administration of any other sort of convulsive therapy; the administration of any form of psychosurgery; the administration of any type of implant device(s) used for a psychiatric purpose; detention in a psychiatric facility or any other facility for a psychiatric reason.

I have advance directive documents completed in my state relating to health care.
(Please check yes or no)

If yes, please check all applicable types of advance directive documents and list their respective effective dates (month, date, year)

Contact Person

Please list the name and contact information of a person you trust who can contact MindFreedom on your behalf regarding your MindFreedom Shield and whom MindFreedom may contact if your MindFreedom Shield needs to be activated. The person you choose must also sign this form as indicated below.

Phone Number(s)
(Please be sure to include area code)

If you have established advance directive documents, is this person an agent whom you have designated on these documents?

If no, please list the name and contact information of a person who has access to an original copy(ies) of your state specific advance directive document(s). You may also use this section to list the alternate agent specified on your directive documents or, if you have not established advanced directive documents, to list a second contact person .

Phone Number(s)
(Please be sure to include area code)

By checking the following checkbox, I acknowledge that:

I have read, voluntarily completed and understand all of the contents of this document. This document is not a legal will, power of attorney or other kind of advance health care directive document. I agree to take responsibility to notify MindFreedom in writing if any information related to this document changes. This document will remain in effect as long as my MindFreedom membership is current; or, until I request in writing (including a dated signature) that this document be revoked; or, until MindFreedom, at its discretion and with sufficient notice, alters or ends this program. I further understand that MindFreedom reserves the right to decide at its discretion whether or not to issue a human rights alert to the MindFreedom Solidarity Network upon being notified of and subsequently verifying individual situations; that MindFreedom generally words human rights alerts as allegations made by an individual against licensed professionals or facilities; that MindFreedom can not guarantee results once an alert has been issued and that I may be subjected to coerced or forced psychiatric treatment, including retaliation, even after this document is registered or after a human rights alert has been issued on my behalf. Furthermore, I agree not to hold MindFreedom or any of its staff, sponsoring organizations, 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 document. Finally, all conditions listed in this subsection shall also apply equally to the people I have listed above as a contact person or as a person who has access to copy(ies) of my personal, state specific advance directive documents.

I agree with the above terms of the MindFreedom Shield registration.

Permission for Release and Exchange of Information

By signing this portion of the MindFreedom Shield Form, I, , authorize the following:

1. Designated Contact Person(s).
   I authorize the contact person(s) designated or listed above to contact MindFreedom Support Coalition International and to communicate with MindFreedom on an ongoing basis as needed, including responding if being contacted by MindFreedom, in the event I am subjected to coerced or forced psychiatric treatment.
2. MindFreedom Human Rights Alert.
   I authorize the staff of MindFreedom Support Coalition International, or designees thereof, to issue, if necessary, a human rights alert regarding my situation. I understand that such an alert will be made public and may contain personal and medically-related information about me necessary to explain that I am being subjected to coerced or forced psychiatric treatment to facilitate action on my behalf to end or reduce the imposition of coerced or forced psychiatric treatment. Additionally, I understand that information contained in human rights alerts will vary based on each situation but may include my name, location (city), listing of the psychiatric diagnosis(es) I have been labeled with, a description of the coerced or forced psychiatric treatment I am being subjected to including information about where/how such treatment may be/is taking place, names and contact information of licensed professionals or facilities alleged to be imposing coerced or forced psychiatric treatment on me (which may include the name of and professional contact information for my treating physician(s)/psychiatrist(s).
3. Licensed Professionals and Facilities.
   I hereby authorize and direct any and all licensed professionals or facilities alleged to be subjecting me to coerced or forced psychiatric treatment and who are contacted by MindFreedom Support Coalition International upon activation of my MindFreedom Shield, to comply with MindFreedom's requests for information regarding me including information about my treatment. Upon activation of my MindFreedom Shield, this authorization for release of information is renewed every forty-five (45) days until such time as my MindFreedom Shield has been deactivated.
4. Media.
   I authorize MindFreedom Support Coalition International to contact and communicate with the media on my behalf if my MindFreedom Shield is activated and a Human Rights Alert has been issued on my behalf.

Comments/Specific Instructions

You may use this portion of the MindFreedom Shield form to note any additional information we should know or specific comments, instructions or exceptions applicable to you.

If you have any questions about this form, please contact the MindFreedom office before registering this form with us. Upon completion of this form, please keep a copy for yourself and give a copy to the contact person(s) you have designated on this form. Please do not e-mail a completed form.

MindFreedom Support Coalition International
454 Willamette, Suite 216 - POB 11284
Eugene, OR 97440-3484 USA

On the next page, you will be presented with a printable form containing the information that you completed above. Please sign and date this form and submit it to MindFreedom as indicated.