Mental Health Care Act, 2002 (Act No. 17 of 2002)

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General Regulations

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Form MHCA 04

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ANNEXURE

FORM MHCA 04

DEPARTMENT OF HEALTH

APPLICATION TO THE HEAD OF HEALTH ESTABLISHMENT CONCERNED FOR ASSISTED OR INVOLUNTARY CARE, TREATMENT AND REHABILITATION

(Section 27(1) and 27(2) or 33(1) and 33(2) of the Act)

(A staff member assisting the Applicant in completing this form must record his/her name, surname and designation)

Name, surname and designation of staff member ....................................................................................................

A. INFORMATION REGARDING THE USER

I hereby apply for —

assisted care

or involuntary care

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

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

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

Gender:

Male

Female

Marital status:

Employment:

Yes

or No

Property:

Yes

or No

Income source:

Pension

Grant

Other

Specify.......................................

None

Is there a reason to believe that an administrator or curator needs to be appointed to manage the financial affairs of the User

Yes

or No

Residential address and contact details: .................................................................................

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

B. INFORMATION REGARDING APPLICANT

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

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

Date of birth .....................................(must be over 18 years of age) ....................

Residential address and contact details: .....................................................................................

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

C. RELATIONSHIP BETWEEN APPLICANT AND MENTAL HEALTH CARE USER: (mark with a cross)

Spouse

Partner

Associate

Parent

Guardian

Health Care

Provider

Other

Specify.............................................................................

(If User is under 18 this application must be made by the parent, caregiver, guardian or person with parental right and responsibilities)

I last saw the User on .................... at .......................................

(date) (time) (place)

(The applicant must have seen the User within seven days of making this application)

D. WHY IS THE APPLICANT THE HEALTH CARE PROVIDER?

The spouse, next of kin, partner, associate, parent or guardian of the User is:

(i)	Unwilling (State reasons for this conclusion):

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

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

(ii)	Incapable (State Reasons for this conclusion):

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

(iii)

Unknown/Untraceable (state efforts made to trace)

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

E. REASONS FOR THE APPLICATION:

I, the undersigned, am of the opinion that the above-mentioned person is suffering from a mental illness / intellectual disability for the following reasons (e.g. what did he/she do or say?):

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

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

F. IN THE CASE OF AN APPLICATION FOR INVOLUNTARY CARE:

In your opinion:

(i)	Is the User a danger to self and others due to his/her mental illness?

Yes

(ii)	Is the User willing to receive care, treatment and rehabilitation if needed?

Yes

(iii)

Is the User able to make an informed decision?

Yes

I also attach the following information in support of my application (if available)

Medical certificates:

History of past mental illness:

/ intellectual diability:

Other

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

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

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

I wish to have representation / Legal Representation / Legal Aid

for myself

Yes

or on behalf of the User

Yes

Print initials and surname (Applicant) .........................................................................................

Signature (Applicant): .................................................................................................................

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

Place: ..........................................................................................................................................

Note: Applicant must sign under oath...........................................................................................

F. OATH / AFFIRMATION

I certify that:

iii. The deponent acknowledged to me that:

a.	He/she knows and understands the contents of this declaration;

b.	He/she has no objection to taking the prescribed oath;

c.	He/she considers the prescribed oath to be binding on his/her conscience;

iv.	The deponent signed this declaration in my presence at ........................................ on this.............. day of ................................ 20.....

______________________________________________________

Signature: Commissioner of Oath: Ex-Officio

Name: ....................................................................................

Rank / Designation: .................................................................

(Submit original to Review Board)

Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 04

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