ANNEXURE

FORM MHCA 01

DEPARTMENT OF HEALTH

REPORT TO MENTAL HEALTH REVIEW BOARD ON PROVISION OF CARE, TREATMENT AND REHABILITATION WITHOUT CONSENT OR EMERGENCY ADMISSION

(Section 9(2) of the Act)

Surname of User .....................................................................................................................

First name(s) of User  ...............................................................................................................

Date of birth  ...............................................or estimated age ....................

Residential address:

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

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

Date of admission:

Time of admission:

Name and health establishment:

Reason for admission without consent:

Based on my/practitioners at this health establishment's assessment, any delay in providing care, treatment and rehabilitation services / admission may, due to mental illness, result in:

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

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

(c)        the User causing serious damage to or loss of property belonging to him/herself or to others

Reasons for this assessment (including mental health status and behavioural reasons)

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

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I ................................................................. (name of mental health care practitioner) hereby declare that I have personally assessed ........................................................

(name of mental health care user) at ..................................................................

(name of health establishment) on ......................................(date).

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

Designation: .............................................

Contact Numbers: .....................................

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

Signature:

Outcome of assessment within 24 hours—

Date of application ..................................... Time of application......................

Print initials and surname....................................................

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

Signature:

Date: ...............................................

(Submit to relevant Review Board)