ANNEXURE

FORM MHCA 27

DEPARTMENT OF HEALTH

GRANTING OF LEAVE OF ABSENCE TO A STATE PATIENT, ASSISTED OR INVOLUNTARY MENTAL HEALTH CARE USERS

(Section 45, 66 (1)(j) of the Act)

Surname of assisted or involuntary mental health care user  ............................................................

First name(s) of assisted or involuntary mental health care user .......................................................

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

Residential address or custodian's name and address whilst on leave of absence:

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

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

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

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

The User is :  (mark with a cross)

Date of commencement of leave: .......................................

Due date of return from leave: ............................................

Name of health establishment where the User's mental health status will be monitored and reviewed:

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

The User is to prevent him / herself to this health establishment every .................weeks / months to be monitored and his / her health status reviewed.

Name of health establishment(s) where care, treatment and rehabilitation will be provided and the nature of this:

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

Conditions of behaviour which must be adhered to by the User:

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

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

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

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

Name of psychiatric hospital where the User is to be admitted if he / she relapses and / or is not complying with the terms and conditions applicable to the leave:

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

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

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

                      (Head of health establishment)

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

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

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

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

                      (custodian)

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

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