Diamonds Act, 1986
R 385
Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 13A |
ANNEXURE
FORM MHCA 13A
DEPARTMENT OF HEALTH
PERIODICAL REPORT ON MENTAL HEALTH CARE USER (ASSISTED/INVOLUNTARY USER/MENTALLY ILL PRISONER)
(Sections 30(2), 37(2) and 55(1) of the Act)
Section 1: Biographical information
Surname of User ..........................................................................................
First name(s) of User ....................................................................................
Date of birth ........................................or estimated age ....................
|
Gender:
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Male |
Female |
The User is an: (mark with a cross)
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Assisted User
|
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Involuntary User |
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Mentally ill prisoner |
Name of health establishment concerned: ............................................................................
Registration number (if any): .................................................................................................
Date of first admission of mental health care user under this section: ....................................
Section 2: Assessment
Mental health status: (Short statement of the mental health status before and since admission, since the last report, and the present condition, with special reference to any symptom indicating homicidal, suicidal or dangerous tendencies)
Before admission:
...............................................................................................................................................
................................................................................................................................................
...............................................................................................................................................
Since admission / previous periodical report:
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Physical condition of User:
................................................................................................................................................
................................................................................................................................................
.................................................................................................................................................
Diagnosis:
..................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
Section 3: Clinical management, treatment and rehabilitation plan
Present treatment programme to be followed, including psycho-pharmacological, ECT, occupational therapy or psychotherapy social work intervention with family, leave of absence to family, etc):
Medical:
..................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Psychological:
....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................
Social (including the safeguarding of the User's financial interests):
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Occupational:
.................................................................................................................................................
..................................................................................................................................................
..................................................................................................................................................
Physiotherapy (if required):
...................................................................................................................................................
...................................................................................................................................................
...................................................................................................................................................
Family contacts:
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Personal
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Correspondence |
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Regular |
Seldom |
Never |
In the case of never, what has been done to trace to family?
............................................................................................................................................
.............................................................................................................................................
..............................................................................................................................................
Section 4: Recommendation in terms of Section 30 or 37 or 55(1)
| (a) | The User is suffering from a mental illness or severe/profound mental diability and requires care, treatment and rehabilitation services for his/her health or safety or the health or safety of other people or for the protection of the financial interests or reputation of the User; |
| (b) | The User is currently incapable of making an informed decision on the need for the care, treatment and rehabilitation services |
and
|
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not refusing |
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care, treatment and rehabilitation services |
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Should the User status remain unchanged?
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Yes |
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No |
Briefly motivate:
.....................................................................................................................................
.......................................................................................................................................
If the User is an involuntary impatient, should he / she be transferred to involuntary outpatient care?
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Yes
|
No |
Briefly motivate:
................................................................................................................................................
................................................................................................................................................
Please add additional paper if required, as this is extremely important:
................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
.................................................................................................................................................
................................................................................................................................................
................................................................................................................................................
Print initials and surname of assessing practitioner: ..............................
Signature: .............................................................................................
(assessing practitioner)
Date: ....................................................................................................
Place: ....................................................................................................
Section 5: Instructions and remarks
..................................................................................................................................................
..................................................................................................................................................
...................................................................................................................................................
Signature: ................................................................................
(Head of health establishment)
Date: .......................................
Place: .................................................................
'(Original to Review Board and copy of report in case of mentally ill prisoner to relevant magistrate, administrator, if appointed, and head of relevant prison'
