Mental Health Care Act, 2002 (Act No. 17 of 2002)

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General Regulations

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Form MHCA 30

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ANNEXURE

FORM MHCA 30

DEPARTMENT OF HEALTH

APPLICATION FOR DISCHARGE OF STATE PATIENT TO JUDGE IN CHAMBERS (WHERE APPLICANT IS 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 ....................

Gender: Male □ Female □

Address: ..................................................................................................................

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

Date of admission: ...................................................................................................

Charge against User: .................................................................................................

Date declared a state patient: ...................................................................................

Health establishment where User is being treated: ....................................................

Application for discharge made by official curator ad litem / other: .............................

If other, state whom: ...................................................................................................

Has an application been made for discharge of the state patient within the preceding 12 months by any applicant other than official curator ad litem?

Yes □ or No □

If yes, provide details of the status of that application (and no need to further with this form)

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

Report from psychologist (attach if available) Yes □ or No □

Attach reports containing the history of the User's mental health status and a prognosis concerning their mental health status from:

(a) Head of the relevant health establishment

(b) Two mental health care practitioners at least one of whom should be a psychiatrist

Recommendations and comments on whether the application should be granted:

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

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

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

(Official curator ad litem / administrator)

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

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

Psychiatric report in terms of section 47(2) and 47(3)(a) of the Act

General information regarding;

(a) escapes / attempted escapes

(b) violent behaviour

(d) attempts at obtaining alcohol and dagga

(e) any other unacceptable behaviour

Summarized history of User's mental health status:

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

Description of present mental condition:

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

Prognosis:

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

Recommendation(s):

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

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

(head of health establishment

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

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

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

Psychiatric report in terms of section 47(2) and 47(3)(a) of the Act by a psychiatrist / medical practitioner

Educational qualifications: ..........................................................................................

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

Occupation of state patient before admission: ............................................................

Nature of charge: .........................................................................................................

Review of medical and psychiatric history before admission:

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

Present mental state and duration:

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

Diagnosis:

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

Treatment received in hospital:

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

Prognosis:

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

Recommendations:

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

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

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

(psychiatrist / medical practitioner)

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

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

Psychiatric report in terms of section 47(2) and 47(3)(a) of the Act by a psychiatrist / medical practitioner

Educational qualifications ......................................................................................................

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

Occupation before admission ................................................................................................

Nature of charge ...................................................................................................................

Review of medical and psychiatric history before admission:

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

Present mental state and duration:

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

Diagnosis:

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

Treatment received in hospital:

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

Prognosis:

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

Recommendations:

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

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

(psychiatrist / medical practitioner)

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

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

Mental Health Care Act, 2002 (Act No. 17 of 2002)

Regulations

General Regulations

Annexures

Form MHCA 30

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