ANNEXURE

FORM MHCA 38

DEPARTMENT OF HEALTH

APPLICATION TO MAGISTRATE FOR CONTINUED DETENTION OF A MENTALLY ILL PRISONER

(Section 58(3) of the Act)

Surname of mentally ill prisoner: ..................................................................................

First name(s) of the prisoner:  .......................................................................................

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

Health establishment concerned: ...................................................................................

File No: ...........................................................................................................................

Prison number: ...............................................................................................................

Charge against prisoner: ..................................................................................................

The above mentally ill prisoner has been admitted at:

...........................................................................................................(name of health establishment)

as a mentally ill prisoner since:  ..........................................................(date of admission)

The date of expiry of his / her prison sentence is: ..................................................... (date of expiry of sentence)

Application for further confinement of the User in terms of Chapter V of this Act was made on ........................................... by ................................................................

In terms of section 58(3) of the Act, I hereby request permission to keep this User at this health establishment and provided care, treatment and rehabilitation pending the outcome of the application.

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

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

                     (head of health establishment)

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

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