ECT Patient Info
Please fill out this form if you have experienced any side effects, such as cognitive impairment or memory loss, after having been administered electroconvulsive therapy and we may be able to provide you with legal counsel and compensation.


*Please Note: No submission of this questionnaire by an ECT patient creates an attorney-client relationship. Only upon execution of a signed retainer agreement will an attorney-client relationship with DK Law Group, LLP be formed.

Email address *
Name *
Your answer
On what dates did you receive ECT? *
Your answer
At what facilities did you receive ECT? *
Your answer
Which doctor gave you ECT? (Optional)
Your answer
How many rounds of ECT did you receive? *
Your answer
What effect did ECT have on you? *
Your answer
When did you notice the effects of ECT? *
Your answer
Are any of these effects permanent? *
Your answer
For evidentiary purposes in a lawsuit, can anyone corroborate the fact that you received ECT? If so, who are they? *
Your answer
Do you have any documents showing that you received ECT? *
Your answer
(Optional) Please describe, in as much detail as you feel comfortable with, your life before ECT as well as any other persisting difficulties or side effects that you attribute to ECT.
Your answer
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