Concerned Public Membership

Your information will be kept secure and will only be shared in the following manner:

1. With immediate members of our administrative team.
2. Your name, specialty and professional credential initials.
3. The above list given to our liaisons to such legislators and/or government officials. This list will have at the top of it the following:

“We, the listed concerned public members of Doctors' Coalition Against Electroconvulsive Therapy believe that electroconvulsive therapy and similar procedures are physically and mentally harmful to patients and should be legally banned from being used on any patient.”

I understand that no additional claims will be made associated with my name.

By completing this form and clicking on the submission button, I agree to the following:

1. That my name and possibly State may be listed on the Doctors' Coalition Against Electroconvulsive Therapy website as a “Concerned Public Member” for public viewing.
2. I will not make any claims or statements on behalf of the Doctors' Coalition Against Electroconvulsive Therapy that are not already used by this organization without approval from its Directors.
3. That my name and possibly State may be on a printed list that may be given to government legislators / officials and/or their Staff for the purpose of communicating with them in related efforts to pass legislation to ban and/or highly restrict electroconvulsive therapy and similar procedures.
4. That if I engage in any activity that is illegal that I will hold harmless the Doctors' Coalition Against Electroconvulsive Therapy and its Directors and Members.
5. That administrative members of Doctors' Coalition Against Electroconvulsive Therapy may contact me by email regarding matters related to this organization.