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

Regulations

General Regulations

Annexures

Form MHCA 36

 

ANNEXURE

FORM MHCA 36

 

DEPARTMENT OF HEALTH

 

ASSESSMENT OF MENTAL HEALTH STATUS OF PRISONER FOLLOWING REQUEST FROM HEAD OF A PRISON AND / OR MAGISTRATE

DISCHARGE OF A STATE PATIENT

(Section 50(2) or 52 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:  

  S

 

M

 

D

 

W

 

 

 

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

 

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

 

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

 

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

 

Prison number: ...........................................................................................................

 

Date of examination: ..........................    Place of examination: ...................................

 

Category of designated mental health care practitioner: ..............................................

 

Physical health status (filled in only by practitioner qualified to conduct physical examination)

 

(a) General physical health:

 

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

 

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

 

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

 

(b) Are there signs of injuries?

 

Yes

 

or           No

 

 

(c) Are there signs of communicable disease?

Yes

 

or           No

 

 

 

 

If the answer to (b) or (c) is Yes, give further particulars:

 

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

 

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

 

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

 

Reports facts on previous observations of mental illness (state who provided this information):

 

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

 

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

 

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

 

Facts concerning the mental condition of the prisoner which were observed on previous occasions (State dates and places):

 

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

 

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

 

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

 

Mental health status of the User at the time of the present examination:

 

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

 

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

 

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

 

Type of illness (provisional):

 

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

 

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

 

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

 

In my opinion the above-mentioned prisoner—

 

has homicidal tendencies:

 

Yes

 

or           No

 

 

has suicidal tendencies:  

 

Yes

 

or           No

 

 

is dangerous:          

 

Yes

 

or           No

 

 

Recommendation to head of prison

 

The prisoner is mentally ill and requires care, treatment and rehabilitation:  

 

Yes

 

 

or           No

 

 

In my opinion the prisoner can be given care, treatment and rehabilitation with the prison and / or in a prison hospital:

 

Yes

 

 

or           No

 

 

In my opinion the mental illness is of such a nature that the prisoner should be sent to a psychiatric hospital for care, treatment and rehabilitation:

 

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

 

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

 

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

 

Plan for care, treatment and rehabilitation for prisoner:

 

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

 

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

 

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

 

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

 

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

 

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

 

 

 

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

 

 

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

        (mental health care practitioner who assessed mental health status of prisoner)

 

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

 

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