ANNEXURE

FORM MHCA 09

DEPARTMENT OF HEALTH

NOTICE BY HEAD OF HEALTH ESTABLISHMENT AFTER 72-HOUR ASSESSMENT PERIOD INFORMING REVIEW BOARD THAT MENTAL

HEALTH CARE USER WARRANTS FURTHER INVOLUNTARY CARE,  TREATMENT AND REHABILITATION ON AN OUTPATIENT BASIS

(Section 34 (3)(b) of the Act)

I .......................................................................................................hereby inform

(name of head of health establishment)

the Review Board that  ..........................................................................................

                                              (name of mental health care user)

requires further involuntary care, treatment and rehabilitation on an outpatient basis.

I am satisfied that the restrictions and intrusions on the mental health care user's right to movement, privacy and dignity are proportionate to the care, treatment and rehabilitative services contemplated.

The basis of this request for further involuntary care, treatment and rehabilitation on an outpatient basis is that:

Signature: .............................................................................................

(Head of health establishment)

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

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

[Copy to mental health care user and original to Review Board]