The Wellbeing Foundation: ECT Survey

ECT AND YOU: a survey

Thank you for visiting this web page and for participating in our survey

All personal details are optional. You do not have to submit your name, address or telephone number if you would prefer not to.

However, the Institute of Psychosocial Medicine is carrying out further research on user experiences of ECT. If you would like to share your experiences of ECT with us, please do submit these details and a researcher will make contact with you.

fields marked with a red star (*) are required

First Name
Last Name
Street Address
City
County
Telephone
Email Address *
How Did You Hear About Us? *
Are you male or female? *
What is your age range? *
Have you ever received ECT (Shock Therapy)? *	Yes No
If yes, at what age did you first receive ECT?
Total number of times you received ECT Total number of times you received ECT
Has a member of your family ever received ECT? *	Yes No
If yes, is your family member male or female?
Family member's age range
At what age did he/she first receive ECT?
How many times in total?

Thank you for your interest in our survey

If you prefer, you may print out the survey form above and send it to us by post.
Please address all mail to Miriam Galvin at the address below.

2 Eden Park | Glasthule | Dun Laoghaire