ANNEXURE

FORM MHCA 08

DEPARTMENT OF HEALTH

NOTICE BY HEAD OF HEALTH ESTABLISHMENT TO REVIEW BOARD REQUESTING APPROVAL FOR FURTHER INVOLUNTARY CARE,

TREATMENT AND REHABILITATION ON AN INPATIENT BASIS

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

I .......................................................................................................hereby request the

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

(name of head of health establishment)

approval from the Review Board for further involuntary care, treatment and rehabilitation on an inpatient basis of:

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

(name of Use)

The findings of the mental health care practitioner and medical practitioner are that the User requires further involuntary care, treatment and rehabilitation.

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 inpatient basis is that:

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

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Attached hereto please find the copies of the following—

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

(Head of health establishment)

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

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

[Original to Review Board & Copy (excluding attachment) to applicant]