ANNEXURE

FORM MHCA 15

DEPARTMENT OF HEALTH

APPEAL TO REVIEW BOARD AGAINST DECISION OF HEAD OF HEALTH ESTABLISHMENT ON ASSISTED - OR INVOLUNTARY MENTAL HEALTH

CARE, TREATMENT AND REHABILITATION

(Section 29(1) and 35(1) of the Act)

Details of User

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

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

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

Residential address:

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If No to the above:

Surname of appellant  ...............................................................................

First name(s) of appellant   ........................................................................

Contact number of appellant  .............................................. or estimated age .............

Residential address:

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Relationship between appellant and mental health care user:  (mark with a cross)

Grounds for the appeal:

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Facts on which the appeal is based:

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I, the undersigned wish to have representation/Legal Representation / Legal Aid for myself or on behalf of ................................................(put in a tick box for yes or no)

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

(appellant)

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

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