Statistics Act, 1999
R 385
Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 17 |
ANNEXURE
FORM MHCA 17
DEPARTMENT OF HEALTH
DECISION /RECOMMENDATION BY REVIEW BOARD FOLLOWING PERIODIC REVIEWS / REPORTS ON ASSISTED OR INVOLUNTARY
MENTAL HEALTH CARE USERS OR MENTALLY ILL PRISONERS
(Sections 30(4), 37(4) or 55(4) of the Act)
Surname of User ..................................................................................................
First name(s) of User ............................................................................................
Date of birth .............................or estimated age ....................
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Gender:
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Male |
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Female |
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Occupation ..................................................................................................... |
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Marital status: |
S |
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M |
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D |
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W |
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Health establishment concerned ..............................................................................
(name of health establishment)
The Review Board of .................................................................................... have considered
| (name of Review Board |
documentation and issues relevant to the periodic review of the above User.
The Review Board has considered (inter alia) whether:
| (a) | The User is capable of making an informed decision on the need to receive care, treatment and rehabilitation services. |
| (b) | The User is suffering from a mental illness or severe or profound intellectual disability, and as a consequence of this requires care, treatment and rehabilitation for his / her health and safety or the health and safety of others. |
| (c) | The User is willing to receive care, treatment and rehabilitation services. |
| (d) | The User is likely to inflict serious harm on him / herself or others. |
| (e) | care, treatment and rehabilitation is necessary for the User's financial interest and reputation. |
| (f) | The User's right to movement, privacy and dignity will be unnecessarily restricted. |
The Review Board have requested the following people to make oral or written representations:
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(a) Applicant
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(b) Independent mental health care practitioner(s)
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(c ) Head of health establishment
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(d) Others (Specify)
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The Review Board has decided / recommend that:
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(a) the User should be discharged
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outpatient |
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Reasons for this decision / recommendation:
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Print initials and surname: ....................................................................
Signature: .............................................................................................
(Chairperson of Review Board)
Date: ....................................................................................................
Place: ....................................................................................................
[Copies to be sent in the case of:
Assisted or involuntary User: to the mental health care user, applicant, head of health establishment concerned and head of provincial department;
Mental ill prisoners: mentally ill prisoner, administrator/curator (if appointed) head of health establishment concerned, relevant magistrate, head of relevant prison and head national department.]
Periodic Report No. ............................................ is due on ..................................
