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 *
Last Name *
I am *
Where do you reside? (City, state or province & country) *
How can we contact you?
A valid email address or phone number is required.
Email
Phone number
Your ECT History
What was the last year you received ECT?
What is the name of the facility you received ECT from?
What city, state (or province), and country did you receive ECT in? *
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