World Network of Users and Survivors of Psychiatry

Family name :
Other names :
Address :
City :
State
Postal/Zip Code :
Country :
Phone :
Fax :
Email address :
Remarks :
Are you a user/survivor of psychiatry ?	Yes No
Are you a member of a user/survivor of psychiatry organisation ?	Yes No
If yes, please give the name of the organisation:

Notes:

The minimum information we need are those in bold
Phone and fax numbers – please include country code and any local codes – e.g. +61 3 9999 1234 is phone number 9999 12324 in Australia (61), state of Victoria (3)
Remarks – if you wish to give us some (brief) extra information – e.g. the URL of your website if you have one.