Cap. 525 Art. 48Saving. Cap. 262. Disorders. of M / F .............. (Sex) for for Order. No) (Time) forward this the person being IN M / F .............. (Sex) the above for apply/do my opinion: (Reg. No) .......................... (Time) To be filled by a second specialist in mental health in the case of a discre

PART XI

In KraftAmtlicher Text

(1) Any regulations or orders made under the provisions of the Mental Health Act, hereinafter referred to as "the repealed

Act" and still in force on the commencement of this Act shall, until provision is made by or by virtue of this Act, continue in force and have effect as if made under this Act.

(2) Any action or proceedings taken in relation to any person under the repealed Act shall continue to have effect as if it were an action or proceedings taken or commenced under a corresponding provision of this Act. Act RFC Ref No: APPLICATION TO RESTRICT FREEDOM OF COMMUNICATION To the Commissioner for the Promotion of Rights of Persons with Mental To be filled by (1) Please approve my request to restrict freedom responsible communication in respect specialist in of: mental health. ................ .................... ............... ..................... (Surname) (Name) (ID No) (D.O.B.) of (address) ......................................................................................... .........................................................................................

who was admitted at ............................ (ward) on ............................

(date) as

 a voluntary patient

 an involuntary patient under an Involuntary Admission Observation,

 an involuntary patient under an Involuntary Admission Treatment Order,

 an involuntary patient under a Continuing Detention

(2) Give details of communication to be restricted: .................................................................................................... ....................................................................................................

(3) Give reasons for such restriction: .................................................................................................... .................................................................................................... ....................................................................................................

........................ .......................... .................... (Official Stamp) (Signature) (Reg.

........................ ........................... (Date)  Request approved  Request not approved

My decision was communicated in writing to the responsible specialist on (date) ................................

............................. ............................... .......................... (Signature) (Date) (Time) Act medical recommendation. The Clinical Director shall application to the Commissioner within 48 hours of admitted. IAO Ref No: APPLICATION FOR A PERSON TO BE ADMITTED INVOLUNTARILY FOR OBSERVATION A LICENSED MENTAL HEALTH FACILITY To the Clinical Director Employed by the Licensed Mental Health Facility PART (A) - MEDICAL RECOMMENDATION Please make an Involuntary Admission for Observation for: ................... .................... ............... .................... (Surname) (Name) (ID No) (D.O.B.)

of (address) .................................................................................................................... .................................................................................................................... To be filled by I am a medical practitioner and have personally examined medical person. practitioner. It is my opinion that the criteria for Involuntary Admission Observation of the Mental Health Act (delete as applicable) not apply to the person. I base my opinion on the following facts: ............................................................................................................. ............................................................................................................. ............................................................................................................ .............................................................................................................

Facts communicated to me by another person to support ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

............................ ............................... .......................... (Name and Surname) (Signature)

........................... (Date) I base my opinion on the following facts:

............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

Facts communicated to me by another person to support my opinion: ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

.............................. ............................... .......................... (Name and Surname) (Signature) (Reg. No)

........................... ...........................

(Date) (Time) I am a specialist in mental health and have personally examined the above mentioned person. It is my opinion that the criteria for Involuntary Admission for Observation of the Mental Health Act (delete as applicable) apply/do not apply to the person. I base my opinion on the following facts:

.............................................................................................................

............................. ............................... .......................... (Name and Surname) (Signature) (Reg. No)

........................... ..........................

(Date) (Time) To be filled by I ............................................................ ID No ............................ responsible (address) ............................................................................................ carer over the ............................................................................................ age of 18 years.  Request that .............................................. ID Application is be involuntarily admitted for observation in a valid if Part [A] health facility. has been filled.  Do not request that .................................... ID be involuntarily admitted for observation in a health facility.

I am the responsible carer for the above person by

 a relative [state relationship] ......................................

 appointed by above person to be his responsible evidence]

 others, I am his ...................................... [submit

............................ ............................... (Signature) (Date) PART (C) - APPLICATION BY MENTAL WELFARE OFFICER Please make an Involuntary Admission for Observation for: To be filled by I .................................................................. ID No approved a mental welfare officer appointed by the Minister mental welfare Mental Health Act request that ....................................... officer if .......................... be involuntarily admitted for responsible licensed mental health facility. carer does not I certify that: agree that person needs  the responsible carer has not agreed to such an admission an involuntary admission or  the responsible carer can not be found responsible carer is absent.  I have reviewed the above named person

 there are valid reasons for an involuntary admission observation

 in my opinion it is not safe to give the required community Mental Health Act have reviewed .................................................... ID No ........................... and in my opinion the named person does not need an involuntary admission for observation in a licensed mental health facility because (specify)

........................................................................................................... ........................................................................................................... ........................................................................................................... ...........................................................................................................

............................. ............................... .......................... (Signature) (Date) (Time) be filled by the Clinical Director of the Mental Health Facility after the been admitted whom this application refers:

admitted on ward ................. on (date) .................. at (time) .................

the care of (responsible specialist) .................................................

............................... ......................... ........................... ....................... (Official Stamp) (Date) (Time) Notification received on (date) ...................... at (time) ....................

Comments

............................... ............................ .......................... (Signature) (Date) (Time) Act hours that a person is admitted to a licensed mental an involuntary patient for observation. IATO Ref No: APPLICATION FOR A PERSON TO BE ADMITTED INVOLUNTARILY FOR ORDER To the Commissioner for the Promotion of Rights of Persons with Mental Please grant an Involuntary Admission for Treatment Order for: ................... .................... ............... ..................... (Surname) (Name) (ID No) (D.O.B.)

who was admitted at (ward) .................... on (date) ....................... at under an Involuntary Admission for Observation (IAO Ref No) .......................... To be filled by I am the responsible specialist of the above mentioned responsible terms of the Mental Health Act. It is my opinion that: specialist in

(a) the criteria for Involuntary Admission under the mental health. Act apply to the person. I base my opinion on the following ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

(b) the person requires to be detained in this mental beyond the period of observation laid down in the said treatment. I base my opinion on the following facts: ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

A multidisciplinary care plan is submitted with

............................ .............................. .......................... (Official Stamp) (Signature)

.......................... ........................... (Date) .............................. ............................. .......................... (Signature) (Date) (Time)

Case reviewed on (date) ........................

DECISION

Involuntary Admission for Treatment Order granted for a period of ................... (weeks) and shall expire on (date) .............................

Involuntary Admission for Treatment Order not granted because: ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

My decision was communicated in writing to the responsible specialist on (date) ............................. .

............................. ............................... .......................... (Signature) (Date) (Time) Act hours before the termination of the initial Involuntary Treatment Order. EIATO Ref No: APPLICATION FOR EXTENSION OF INVOLUNTARY ADMISSION FOR TREATMENT To the Commissioner for the Promotion of Rights of Persons with Mental Please extend the Involuntary Admission for Treatment Order for: M ................. ................ .............. ................ .............. (Surname) (Name) (ID No) (D.O.B.) (Sex)

granted on (date) ................... IATO Ref No ................. and due to expire To be filled by I am the responsible specialist of the above mentioned responsible of the Mental Health Act. It is my opinion that: specialist in

(a) the criteria of the Mental Health Act for Involuntary mental health. still apply to the person. I base my opinion on the following ............................................................................................................. ............................................................................................................. .............................................................................................................

(b) the person requires to be further detained in this for treatment. I base my opinion on the following facts: ............................................................................................................. ............................................................................................................. .............................................................................................................

(c) the objectives and timeframes of the original multidisciplinary care plan were not attained because (give reasons and objectives were not attained): ............................................................................................................. ............................................................................................................. .............................................................................................................

A modified multidisciplinary care plan is submitted application.

................................... ............................ (Official Stamp) (Signature)

.................................. ................................ (Date) Modified care plan not submitted No

Dr ................................... requested to submit modified care plan

.................................. ............................ .......................... (Signature) (Date) (Time) Case reviewed on (date) ........................

DECISION

Extension of Involuntary Admission for Treatment Order granted for a period of ................... (weeks) and shall expire on

(date) ......................

Extension of Involuntary Admission for Treatment Order not granted because: ............................................................................................................. ............................................................................................................. ............................................................................................................. .............................................................................................................

My decision was communicated in writing to the responsible specialist on (date) ............................. .

................................. ............................ .......................... (Signature) (Date) (Time) Act hours before the termination of the Extended Involuntary for Treatment Order or a Continuing Detention Order. CDO Ref No: APPLICATION FOR A CONTINUING DETENTION ORDER To the Commissioner for the Promotion of Rights of Persons with Mental Please grant/renew a Continuing Detention Order for Involuntary Treatment for: M / ................. ................ ............... ............... .............. (Surname) (Name) (ID No) (D.O.B.) (Sex)

EIATO Ref No........................ / CDO Ref No: .................. due to expire To be filled by I am the responsible specialist of the above mentioned responsible terms of the Mental Health Act. It is my opinion that: specialist in

(a) the criteria of the Mental Health Act for Involuntary mental health. still apply to the person. I base my opinion on the following ............................................................................................................ ............................................................................................................ ............................................................................................................

(b) the person requires to be further detained in this for treatment. I base my opinion on the following facts: ............................................................................................................ ............................................................................................................ ............................................................................................................

(c) the objectives and timeframes of the multidisciplinary submitted with the Application for Extension of Involuntary Admission for Treatment Order/Continuing Detention not attained because (give reasons and indicate which were not attained): ............................................................................................................ ............................................................................................................ ............................................................................................................

A modified multidisciplinary care plan is submitted application.

.................................. .......................... (Official Stamp) (Signature)

............................... ................................ (Date) Modified care plan not submitted No

Dr ................................. requested to submit modified care plan

................................. .......................... .......................... (Signature) (Date) (Time)

 Dr ......................................... an independent specialist was appointed and notified to review person in terms of the Mental Health Act and to submit his opinion by (date) ....................... .

................................. ........................... ......................... (Signature) (Date) (Time) I the undersigned, a specialist in mental health appointed by the Commissioner to review ............................... ID No ................... certify that:

(a) I am not the responsible specialist for the named person

(b) I have reviewed the person for whom this application is being made and in my opinion the criteria for involuntary admission in the said Act are

satisfied not satisfied

I base my opinion on the following facts: ............................................................................................................ ............................................................................................................ ............................................................................................................

I recommend that a Continuing Detention Order be granted / renewed. I base my opinion on the following facts: ............................................................................................................ ............................................................................................................ ............................................................................................................

............................... ............................ .......................... (Official Stamp) (Signature) (Reg. No)

................................ ................................

(Date) (Time) DECISION

 Continuing Detention Order granted / renewed period of ............. (months) and shall expire on (date)

Continuing Detention Order not granted / renewed

............................................................................................................ ............................................................................................................ ............................................................................................................

My decision was communicated in writing to specialist on (date) .......................... .

............................ ............................... (Signature) (Date)

SIXTH SCHEDULE [Article 15(1)]

Mental Health This application shall be submitted to the Commissioner Act RTO Ref No: APPLICATION FOR RELEASE FROM INVOLUNTARY ADMISSION FOR TREATMENT ORDER / CONTINUING DETENTION To the Commissioner for the Promotion of Rights of Persons with Mental To be filled by (1) Please withdraw the responsible Involuntary Admission for Treatment Order, IATO specialist in ................... or mental health.

Extension of Involuntary Admission for Treatment EIATO Ref No: .................. or

Continuing Detention Order, CDO Ref No: ................ on (date) ................... in respect of ................ ................ ............... .............. .............. (Surname) (Name) (ID No) (D.O.B.) Sex)  the Involuntary Admission for Treatment Order/Continuing Detention Order has expired and there is no need to seek an extension. ................................... ............................ ........................ (Official Stamp) (Signature) (Reg. No)

................................... ..............................

(Date) (Time) Application received on (date) .......................... at (time) ..................

Comments

Request approved and my decision was communicated in writing to the responsible specialist on (date) ..................................... .

................................... ........................... ......................... (Signature) (Date) (Time)

SEVENTH SCHEDULE [Articles 17, 18(2)]

This application is only valid for 120 hours from the date of the first medical recommendation and shall be submitted to the Commissioner CTO Ref No: APPLICATION PERSON TO BE PLACED ON A COMMUNITY TREATMENT ORDER Commissioner for the Promotion of Rights of Persons with Mental Disorders grant/renew a Community Treatment Order for: M / F .................. ............... .............. ..............

(Name) (ID No) (D.O.B.) (Sex) ................................................................................................................... detained in a mental health facility under an Involuntary Admission for Order?

IATO Ref No: EIATO Ref No: CDO Ref No:

under a Community Treatment Order?

CTO Ref No: specialist in person. mental health I base my opinion on the following facts: ............................................................................................................

Facts communicated to me by another person to support ............................................................................................................

 The multidisciplinary care plan required in terms Health Act is attached with this application.

Key healthcare professional in terms of Article

Eighth Schedule is enclosed (only if required)

............................ ............................... .......................... Attach care (Name and Surname) (Signature) plan and Eighth ................................. ................................ Schedule if (Date) required PART (B) - MEDICAL RECOMMENDATION BY MEDICAL PRACTITIONER To be filled I am a medical practitioner and have personally examined by medical named person. It is my opinion that the criteria practitioner Treatment Order of the Mental Health Act apply to the

I base my opinion on the following facts: .............................................................................................................. ..............................................................................................................

................................ ............................ .......................... (Name and Surname) (Signature)

................................ ................................ (Date) PART (C) - APPLICATION BY RESPONSIBLE CARER be placed on a Community Treatment Order

 Do not request that ....................................... ID No ...................... be placed on a Community Treatment Order.

I am the responsible carer for the above person by virtue of being:

a relative [state relationship] .............................

 appointed by above person to be his responsible carer [submit evidence]

others. I am his .................................. [submit evidence]

................................... ........................... .........................

(Signature) (Date) (Time)

APPLICATION BY MENTAL WELFARE OFFICER I .................................................... ID No ......................... am a mental welfare officer appointed by the Minister in terms of the Mental Health Act request that ........................................ ID No .................................... be placed on a Community Treatment Order.

I certify that

the responsible carer has not agreed to such an Order

the responsible carer can not be found

I have reviewed the above named person

there are valid reasons for a Community Treatment Order

I .................................................... ID No ......................... am a mental welfare officer appointed by the Minister in terms of the

Mental Health Act have reviewed ........................................ ID No

.................................... and in my opinion the named person does not need a Community Treatment Order because (specify)

................................ ........................... ......................... (Signature) (Date) (Time) Key Healthcare Professional identified

 Medical Treatment is not to be provided specialist

 Medical Treatment is not to be provided practitioner signing Part B of this Schedule

Eighth Schedule submitted

Comments

Decision

 Community Treatment Order granted/renewed ................... (months) and shall expire on (date)

Community Treatment Order not granted/renewed .................................................................................................. My decision was communicated in writing to the:

Responsible Specialist on (date) ...............................

Medical Practitioner on (date) ...................................

Person and / or Responsible Carer on (date) ............................

................................ ........................... (Signature) (Date) with the Seventh Schedule if the medical practitioner giving community treatment to a person is different from the responsible specialist or the medical practitioner signing the recommendation. CTO Ref No: NOTIFICATION AGREEMENT TO GIVE MEDICAL CARE IN THE COMMUNITY Commissioner for the Promotion of Rights of Persons with Mental Disorders I the undersigned, a medical practitioner, agree to provide the medical treatment as indicated in the care plan submitted with the application for a Community Treatment Order in respect of:

M / F

................ ................. ................. ............... ...............

(Surname) (Name) (ID No) (D.O.B.) (Sex)

of (address) .......................................................................................... ..........................................................................................

............................... ............................. .......................... (Official Stamp) (Signature) (Reg. No)

................................. ................................

(Date) (Time)

Notification received on (date) ..................... at (time) .......................

Comments

.................................. ............................ .......................... (Signature) (Date) (Time) Mental Health This notification shall be submitted to the Commissioner Act his representative. CO (I) Ref No: CONVEYANCE ORDER BY THE RESPONSIBLE SPECIALIST TO TAKE A PATIENT FOR ASSESSMENT AND/OR TREATMENT To the Commissioner of Police. To be filled I, the undersigned, a specialist in mental health, request by the responsible ................... ................... .................. ................ specialist in (Surname) (Name) (ID No) (D.O.B.) mental health. of (address) .......................................................................................... ..........................................................................................

who is an involuntary patient under the Mental Health subject to:

an involuntary admission for observation;

an involuntary admission for treatment order;

an extension of involuntary admission for treatment

a continuing detention order;

a community treatment order;

be sought, detained and taken to (indicate facility) ........................... on (date) .......................... at (time) .......................... and/or treatment.

................................ ............................. (Official Stamp) (Signature)

................................... ............................. (Date) This notification shall be submitted to the Commissioner of Police or his representative. CO (II) Ref No: CONVEYANCE ORDER BY THE MINISTER RESPONSIBLE FOR JUSTICE TAKE A PATIENT FOR ASSESSMENT AND/OR TREATMENT Commissioner of Police. I the undersigned, the Minister responsible for justice, request that: M / F ................. ................... ................... ................. ............. (Surname) (Name) (ID No) (D.O.B.) (Sex)

of (address) .......................................................................................... ..........................................................................................

who is an involuntary patient under the Mental Health Act and is subject to:

a court order be sought, detained and taken to (indicate facility) ........................... on (date) .......................... at (time) .......................... for assessment and/or treatment.

................................... ............................... (Official Stamp) (Signature)

................................. ................................

(Date) (Time) Act RCTO Ref No: APPLICATION FOR REVOCATION OF A COMMUNITY TREATMENT To the Commissioner for the Promotion of Rights of Persons with Mental To be filled by (1) Please withdraw the Community Treatment Order, responsible ................ granted on (date) ....................... in respect specialist in mental health. .................. .................. .................. .............. (Surname) (Name) (ID No) (D.O.B.)

This is being recommended because:

the person’s mental health status has improved for community treatment are not fulfilled any more;

the Community Treatment Order has expired and need to seek an extension; OR

the person requires involuntary admission for therapeutic reasons.

.................................. ............................ (Official Stamp) (Signature)

.................................. ............................... (Date) To be filled by Notification received on (date) ..................... at (time) Commissioner Comments

Request approved and my decision was communicated

(a) the responsible specialist on (date) ...........................

(b) the person / responsible carer on (date) .....................

.................................. ........................... ....................... (Signature) (Date) hours of certification. CLMC Ref No: CERTIFICATION OF LACK OF MENTAL CAPACITY Commissioner for the Promotion of Rights of Persons with Mental Disorders.

(1) I the undersigned, a specialist in mental health have personally reviewed:

M / F ................ .................. ................... ................ .............. ............ (Surname) (Name) (ID No) (D.O.B.) (Sex) (Ward)

of (address) ..........................................................................................

and certify that the above named person lacks mental capacity.

(2) The reasons for such decision are: ............................................................................................................. .............................................................................................................

(3) In my opinion, this person lacks mental capacity to take rational decisions regarding: ............................................................................................................. .............................................................................................................

(4) Estimated duration of lack of mental capacity is

 ............................... (weeks) and an application for incapacitation or interdiction is not recommended; OR

more than 26 weeks and an application for incapacitation is recommended; OR

more than 26 weeks and an application for interdiction is recommended. Observation IAO Ref No ..............

an involuntary patient under an Involuntary Admission Treatment Order IATO Ref No .............

an involuntary patient under an Extension of Involuntary Admission for Treatment Order EIATO Ref No .........

an involuntary patient under a Continuing Detention CDO Ref No ..............

an involuntary patient under a Community Treatment CTO Ref No ..............

(6) Is this a new application?

YES

NO CLMC Ref No: ................... which should

(7) The responsible carer is:

.................. ................... .................. ............... (Surname) (Name) (ID No) (D.O.B.)

of (address) .......................................................................................... ..........................................................................................

.............................. ............................... (Official Stamp) (Signature)

................................. ............................... (Date) To be filled by Certification received on (date) ....................... at (time) Commissioner Dr ............................... an independent specialist and notified to review person in terms of the Mental and is to submit his opinion by (date) ............................

.................................. ............................ (Signature) (Date)

(b) I have reviewed the person for whom this certification is being made and

I agree with the certification of lack of mental capacity;

I disagree with the certification of lack of mental capacity for the following reasons: ................................................................................... .................................................................................... ....................................................................................

I agree with the certification of lack of mental capacity but have the following reservations (specify): .................................................................................... .................................................................................... ....................................................................................

.................................. ............................ ......................... (Official Stamp) (Signature) (Reg. No)

.................................. ...............................

(Date) (Time) Certification approved for a period of ......................... and shall expire on ....................

Certification approved for a period of ....................... and shall expire on ............................. with the following amendments:

.................................................................................... ....................................................................................

Certification for more than 26 weeks and a recommendation an application for incapacitation are approved

Certification for more than 26 weeks and a recommendation an application for interdiction are approved.

CLMC Ref No: ......................... is revoked (if

Certification not approved

CLMC Ref No: .............................. is not revoked applicable)

My decision was communicated in writing to the responsible specialist, the person, and the responsible carer on (date)

................................ ............................ (Signature) (Date) hours. RCLMC Ref No: APPLICATION FOR REVOCATION OF A CERTIFICATE OF LACK OF MENTAL CAPACITY Commissioner for the Promotion of Rights of Persons with Mental Disorders.

(1) I the undersigned, a specialist in mental health have personally reviewed:

M / F ................ ................ ................. .............. .............. ........... (Surname) (Name) (ID No) (D.O.B.) (Sex) Ward of (address) .........................................................................................

and certify that the above named person has mental capacity to make different categories and types of decisions and is responsible for his actions.

(2) In my opinion, the Certificate of Lack of Mental Capacity CLMC Ref No: ...................... approved on ......................... is to be revoked.

(3) If applicable, indicate if person is:

a voluntary patient .............................

an involuntary patient under an Involuntary Admission for Observation IAO Ref No ..............

an involuntary patient under an Involuntary Admission for Treatment Order IATO Ref No .............

an involuntary patient under an Extension of Involuntary Admission for Treatment Order EIATO Ref No ..........

an involuntary patient under a Continuing Detention Order CDO Ref No ..............

an involuntary patient under a Community Treatment Order CTO Ref No .............. (Surname) (Name) (ID No) (D.O.B.)

of (address) ......................................................................................... .........................................................................................

................................ .......................... .......................... (Official Stamp) (Signature) (Reg.

................................. ............................... (Date) To be filled by Application received on (date) ...................... at (time) Commissioner Dr ............................... an independent specialist and notified to review person in terms of the Mental is to submit his opinion by (date) ............................

.................................. .......................... (Signature) (Date) To be filled by I the undersigned, a specialist in mental health appointed independent Commissioner to review ................................... ID specialist in certify that: mental health appointed by (a) I am not the responsible specialist for the named Commissioner

(b) I have reviewed the person for whom this application made and

I agree that the above named person has mental to make different categories and types of decisions and for his actions and that Certificate of Lack of Mental CLMC Ref No: ........................ approved on ................................. can be revoked.

I disagree with the application for the following and facts: ................................................................................... ................................................................................... ...................................................................................

................................ ............................ (Official Stamp) (Signature)

.................................. ............................ (Date) Revocation of Certification approved

Revocation of Certification not approved

My decision was communicated in writing to the responsible specialist, the person, and the responsible carer on (date) ................. .

................................. .......................... .......................... (Signature) (Date) (Time) Act forward this application to the Commissioner within person being admitted together with the Second Schedule. IAO Ref No: NOTIFICATION BY SPECIALIST WITH CLINICAL EXPERIENCE OF WORKING WITH MENTAL HEALTH PROBLEMS FOR AN INVOLUNTARY FOR OBSERVATION OF A MINOR To the Clinical Director Employed by the Licensed Mental Health Facility To be filled by I the undersigned, a specialist with clinical experience a specialist with minors with mental health problems, and who has appointed by the Minister in terms of the Mental Health clinical that: experience of working with (a) I have personally reviewed the minor minors with mental health ................ .................. .................. ................ problems and (Surname) (Name) (ID No) (D.O.B.) has so been appointed by of (address) .......................................................................................... the Minister .......................................................................................... in terms of the

(b) The criteria for involuntary admission to a licensed Mental Health facility of the said Act apply to this minor Act.

................................. ........................... (Official Stamp) (Signature)

................................. ................................ (Date) To be filled by Notification received on (date) ....................... at (time) Commissioner Comments

................................. ............................ (Signature) (Date) Part I

SPECIAL TREATMENT LIST

following therapeutic invasive or irreversible interventions for mental as determined by the Minister, may be carried out on a patient with a disorder:

Stereotactic Ablative Anterior Capsulotomy for severe refractory Major Depressive Disorder

Stereotactic Ablative Anterior Capsulotomy for severe refractory Obsessive Compulsive Disorder

Stereotactic Ablative Anterior Cingulotomy for severe refractory Major Depressive Disorder

Stereotactic Ablative Anterior Cingulotomy for severe refractory Obsessive Compulsive Disorder Act IIT Ref No: APPLICATION FOR INVASIVE OR IRREVERSIBLE TREATMENT To the Commissioner for the Promotion of Rights of Persons with Mental To be filled by (1) Please approve my request in respect of: responsible M specialist in ................. ................. ................ .............. ........... mental health. (Surname) (Name) (ID No) (D.O.B.) (Sex)

of (address) .........................................................................................

to undergo invasive or irreversible treatment for his/her disorder.

(2) If applicable, indicate if person is:

a voluntary patient .............................

an involuntary patient under an Involuntary Admission Observation IAO Ref No ..............

an involuntary patient under an Involuntary Admission Treatment Order IATO Ref No .............

an involuntary patient under an Extension of Involuntary Admission for Treatment Order

EIATO Ref No ..........

an involuntary patient under a Continuing Detention CDO Ref No ..............

an involuntary patient under a Community Treatment CTO Ref No ..............

(3) Specify treatment to be given ........................................................

(4) Treatment is to be performed by .................................................

(5) I certify that:

• the patient has the mental capacity to give, and has consent to undergo such treatment;

• the consent is in writing and signed by the person

• there is sufficient evidence-based knowledge about

• the treatment benefits the health needs of the patient;

• every available alternative treatment that could reasonably regarded as likely to produce a sufficient and lasting given to this patient without a sufficient and lasting • proposed treatment;

• reasons for such treatment;

• evidence-based knowledge about this treatment; and

• benefits for this patient.

.................................. .......................... ......................... (Official Stamp) (Signature) (Reg. No)

................................... ..............................

(Date) (Time) Application received on (date) ............................

Action

Comments

Decision

Treatment approved

Treatment not approved

My decision was communicated in writing to the responsible specialist on (date) .....................

....................... .......................... ...................... ........... (Signature) (Official Stamp) (Date) (Time) Act Justice.

APPLICATION FOR LEAVE UNDER ARTICLE 37 FOR A PERSON DETAINED UNDER COURT ORDER To the Minister of Justice. To be filled by (1) I the undersigned, a specialist in mental health, responsible specialist in .................. ................. ................... ............... mental health. (Surname) (Name) (ID No) (D.O.B.)

of (address) ......................................................................................... .........................................................................................

who is an involuntary patient under the Mental Health subject to a court order issued on .............................., leave this facility on special leave from (date) ........................

(date) .............................. as part of his care plan.

(2) Give reasons why special leave is recommended:

(3) The following conditions shall apply if special leave

................................. ............................ (Official Stamp) (Signature)

.................................. ............................... (Date)  Special leave is granted subject to the following conditions:

................... .......................... ........................ ........... (Signature) (Official Stamp) (Date) (Time)

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