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

Regulations

Purchase

ANNEXURE

FORM MHCA 34

DEPARTMENT OF HEALTH

APPLICATION TO REGISTRAR OF THE HIGH COURT FOR AN ORDER AMENDING THE CONDITIONS / REVOKING THE CONDITIONAL

DISCHARGE OF A STATE PATIENT

(Section 48(5) of the Act)

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

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

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

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

Gender:

Male

Female

Occupation

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

Marital status:

Address: ....................................................................................................................

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

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

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

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

I hereby request that the conditional discharge of the above state patient be amended or revoked.

The above state patient has not complied with the following terms and conditions of his/her conditional discharge (explain)

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

and his / her mental heart status has deteriorated (explain)

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

(if applicable) I recommend that the terms and conditions of the discharge be amended along the following lines:

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

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

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

(head of health establishment)

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

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

(Copy to be forwarded to the official curator ad litem and national department)