FORM FOR PATIENT TO REQUEST AN INDEPENDENT ADVISER
See the list of organisations who may be able to help. Only some of them will be able to send someone for a hospital visit.
Advocacy projects may be particularly useful if you are unsure about having ECT. Other groups can give you - or a friend or relative - information and advice and provide useful contacts not just for now but when you are getting better.
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Your Name | |
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Your Ward (if an inpatient) | |
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Please arrange for someone independent from outside the hospital to talk to me about ECT before it is decided whether I have this treatment. Tick the box which applies: The person I would like to visit me as soon as possible to discuss ECT is : | |
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1. A friend/relative. They can be contacted at: (give the person's phone number, or address or name of workplace if you know it) |
Name |
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2. Please ask someone from the organisation named opposite to visit me about ECT |
Name of Organisation |
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Date: |
Signed |
