ECT Media Contact
Complete this form to add your name to the list of ECT victims (or family) willing to tell their story to the local media.
Fill out to the best of your ability. If you cannot remember, just go to the next question.
First Name
Your answer
Last Name
Your answer
I am
Where do you reside? (City, state or province & country)
Your answer
How can we contact you?
A valid email address or phone number is required.
Email
Your answer
Phone number
Your answer
Your ECT History
What was the last year you received ECT?
Your answer
What is the name of the facility you received ECT from?
Your answer
What city, state (or province), and country did you receive ECT in?
Your answer
Comments
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