Statistics Act, 1999
R 385
Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 29 |
ANNEXURE
FORM MHCA 29
DEPARTMENT OF HEALTH
APPLICATION FOR DISCHARGE OF STATE PATIENT TO JUDGE IN CHAMBERS (WHERE APPLICANT IS NOT AN OFFICIAL CURATOR
AD LITEM OR ADMINISTRATOR
(Sections 47(2)(e) of the Act)
Surname of state patient.........................................................................................
First name(s) of state patient ..................................................................................
File No. (if known) ...................................................................................................
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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Residential address: .................................................................................................
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Charge against state patient: ....................................................................................
Person making application (mark with a cross):
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State patient him / herself
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Head of health establishment
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Responsible medical practitioner
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Spouse
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Associate
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Next of kin
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Other
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Reasons for application:
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Has an application been made for discharge of state patient within the preceding 12 months by any application other than an official curator ad litem?
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Yes
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No |
If Yes provide details of the status of that application (and no need to proceed further with this form):
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Report from psychologist (if available):
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Yes |
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No |
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In your opinion does the official curator ad litem have a conflict of interest with the state patient? |
Yes |
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No |
Give reasons:
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Supply proof that a copy of the application has been given to the official curator ad litem concerned.
Where the applicant is an 'associate' state the nature of the substantial or material interest in the state patient:
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Attach all reports you have available relevant to this application.
Provide details of any prior application for discharge that you are aware of:
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Print initials and surname: ..........................................
Signature: ......................................................
(Applicant)
Date: ..........................
Place: ...........................................
