Obsessed - Participate

Are you or someone you know suffering from an anxiety or OCD disorder?

If you or someone you know suffering from an anxiety or OCD disorder and would like him or her to be considered for participation on OBSESSED, please fill out the form below. The information you provide will be submitted directly to the production team that produces Obsessed for A&E Television Networks (AETN). Your information will not be seen by AETN unless presented to AETN by the production team. By submitting this information, you give the right to use the information below in connection with Obsessed.
You acknowledge that you may not receive a response from this submission.

IF YOU BELIEVE THAT THE SITUATION YOU DESCRIBE BELOW REQUIRES URGENT ATTENTION, PLEASE CONTACT AN APPROPRIATE CARE PROVIDER.

If you are chosen to participate you will be required to sign appropriate releases.

All fields are required unless otherwise noted.

Your Name:

Address 1:

Address 2:

optional

Email:

Your Age:

City:

Phone:

xxx-xxx-xxxx

State:

Alternate Phone:

Zip Code:

Are you suffering from an anxiety disorder or OCD or is it a loved one?:

How long have you/they shown symptoms:

Years

Months

Is there a category of OCD/anxiety that you/they fit within?:

What is your occupation?:

If the afflicted person is not you, what is their occupation?:

Name of the person with anxiety disorder or OCD (if not you):

His or her age:

City and State he or she lives in:

His or her relationship to you:

If the afflicted person is not you, are you willing to participate in the documentary process?

Yes

Please briefly describe your/your loved one's anxiety disorder and how it is affecting your/their life:

STORY SUBMISSION FORM

This is a legal document affecting your rights and responsibilities:
please read it carefully before signing

I, agree to complete and submit this story submission form (the "Form") for the purpose of being considered to become a participant in the television show entitled "Obsessed" (the "Program"). I am making the representations, disclosures, and agreements described below in this Form so that Producer will continue to consider me to become a participant in the Series. If any disclosure or representation is false, misleading or incomplete, or if I breach any agreement made in connection with the Series, Producer may remove me from further consideration as a participant. I agree that I have not made, nor will I ever make any false or misleading statements regarding the Program, my participation in the Program, or the person that I am submitting for appearance in the Program ("Subject"). I agree that I have not, nor will I engage in any deceptive or dishonest act with respect to the Program, the intended outcome of the Program, or any confidential knowledge I have with respect to the Program.

Please type in your NAME here which signifies that you are agreeing to the above terms of the Story Submission Form:

Please check this box which signifies that you are agreeing to the above terms of the Story Submission Form.

Confirmation Phone (same as phone above):

Date (mm/dd/yyyy):

Person that is the subject of the story:

Additional Materials Supplied (do not exceed 60 characters.
If none, please write NA):