If you have experienced ECT and would like to add your voice to those of others who are supporting the goals of the CTIP, please print and fill out the following form, and send it to:

I have undergone electroconvulsive therapy (ECT; Shock Treatment) and I know or suspect that I was not truthfully informed of its nature or consequences.

In the interest of protection of future patients, I endorse the statements of Patient's Information about ECT that has been proposed to the FDA by the Committee for Truth in Psychiatry (FDA Docket #84P-0430), and in so doing I become a member of the committee.

Name: ________________________________________________

Address_______________________________________________

Phone: (Optional) ________________________________________________

E-Mail: (Optional) _________________________________________________

Signature_______________________________________________

Additional Comments: