Celexa (violent behavior and suicide)

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Defendant:
(who caused the harm?)

Celexa (violence and suicide)

*Describe your complaint:
(briefly describe the damages you have suffered)

Other prescription drugs you are taking, date started and date finished:

Name of Dr. who prescribed Celexa:

How many suicide attempts have occurred?

Are hospital records available about these suicide attempts?

How many incidents of violent behavior have occurred?

How many police reports are available about these incidents?

*What is the age of the person taking Celexa?

Date Celexa was started (and/or stopped):

Do you have a copy of your medical records?

Yes No

Can you get a copy of your medical records?

Yes No

*First name:

*Last name:

*Email address:

*Confirm email address:

*Phone number(s):

*Zip/Postal Code:

Best time & way to contact you:

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Celexa (violent behavior and suicide)