ANNEXURE

FORM MHCA 31

DEPARTMENT OF HEALTH

ORDER BY JUDGE IN CHAMBERS FOR CONDITIONAL DISCHARGE OF STATE PATIENT

(Sections 47(6)(d) of the Act)

Surname of state patient............................................................................................

First name(s) of state patient .....................................................................................

File No. (if known) .....................................................................................................

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

Residential Address: ................................................................................................

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Nature of charge: ......................................................................................................

The above-mentioned state patient is hereby ordered to

Terms and conditions for conditional discharge —

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Period of conditional discharge ..............................................................................(years)

Name and address of custodian into whose charge the state patient is transferred:

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Where the state patient's mental health status will be monitored and reviewed:

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(name of health establishment)

The state patient is to present him / herself to this health establishment every ................ weeks / months to be monitored and his / her mental health status reviewed.

Name of the health establishment(s) where care, treatment and rehabilitation will be provided (if different from the preceding health establishment) and the nature of this:

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Conditions of behaviour which must be allowed to by the state patient:

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Name of psychiatric hospital / care and rehabilitation centre where the state patient is to be admitted if she / he relapses or if the conditions of the conditional discharge are violated

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

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

                     (Judge in chambers)

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

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