ANNEXURE

FORM MHCA 12

DEPARTMENT OF HEALTH

DISCHARGE OF INVOLUNTARY MENTAL HEALTH CARE USER FROM  INPATIENT TO OUTPATIENT CARE OR CANCELLATION OF THE DISCHARGE

(Section 34(3) AND 34(6) of the Act)

Surname of User .........................................................................

First name(s) of User  ....................................................................

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

Residential address:

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

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

A. Discharge from inpatient to outpatient care

This involuntary inpatient at ..............................................................................................(name of health establishment) has improved to such an extent that he/she should be provided with care, treatment and rehabilitation services as an outpatient as dated on the schedule of conditions attached to this transfer as outlined in the attached MHCA 10.

B. Cancellation of the discharge

This involuntary outpatient previously discharged with prescribed conditions on ...........................................and being monitored and reviewed at ............................................... has not complied with the terms and conditions applicable to his / her discharge / relapsed to the extent of being a danger to him / herself or others if he / she remains an involuntary outpatient, and must be admitted as an involuntary inpatient to

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

(name of health establishment)

Specific reasons for transfer to inpatient care are:

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

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

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

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

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

(Head of health establishment)

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

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