Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 05 |
ANNEXURE
FORM MHCA 05
DEPARTMENT OF HEALTH
REPORT ON COMPLETION OF EXAMINATION AND FINDINGS BY MENTAL HEALTH CARE PRACTITIONER FOLLOWING AN APPLICATION
FOR ASSISTED OR INVOLUNTARY CARE TREATMENT AND REHABILITATION
(Section 27(5) or 33(5) of the Act)
Section 1
Surname of User .........................................................................................
First name(s) of User ..................................................................................
Date of birth ......................................or estimated age ....................
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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Section 2
Date of examination: ..................... Place of examination:.........................................
Physical health status (filled in only by mental health care practitioner qualified to conduct physical examination):
(a) General physical health:
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(b) Are there signs of injuries?
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Yes |
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No |
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(
If yes, please indicated whether you believe this is as a result of abuse?
Yes
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No |
Unsure |
If yes, was this abuse reported / investigated?
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Yes |
No |
(c) Are these signs of communicable diseases?
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Yes |
No |
If the answer to (b) or (c) is Yes, give further particulars:
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Section 3
Information on User received from other person(s) or family (state names and contact details):
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Section 4
Previous mental health history if known (State dates and places):
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Section 5
Mental health status of the User at the time of the present examination (describe symptoms or diagnostic criteria):
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Section 6
Type of illness (provisional diagnosis):
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Section 7
In my opinion the above-mentioned User—
has homicidal tendencies due to mental illness
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Yes |
No |
has suicidal tendencies due to mental illness
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Yes |
No |
is a risk to inflicting serious harm to him/herself or others or causing serious damage to property belong to him/her or other due to mental illness |
Yes |
No |
Section 8
Recommendation to head of health establishment on an application for assisted care, treatment and rehabilitation services only (do not complete section 9 of this form if section 8 is applicable)─
An application was made for assisted care, treatment and rehabilitation services |
or involuntary care |
treatment and rehabilitation services |
| 1. | Is the User suffering from a mental illness and as a consequence of this requires care, treatment and rehabilitation services for their own health and safety or the health and safety of others? |
Yes
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No |
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| 2. | Is the User capable of making an informed decision on the need to receive care, treatment and rehabilitation services? |
Yes
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No |
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| 3. | Is the User willing to receive care, treatment and rehabilitation services? |
Yes
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No |
Section 9
Recommendation to head of health establishment on an application for Involuntary care, treatment and rehabilitation services only (Do not complete section 8 of this form if section 9 is applicable)
| 1. | Is the User suffering from a mental illness and as a consequence of this requires care, treatment and rehabilitation services? |
Yes
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No |
| 2. | Is the User capable of making an informed decision on the need to receive care, treatment and rehabilitation services? |
Yes
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No |
| 3. | Does the User refuse to receive care, treatment and rehabilitation services? |
Yes
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No |
| 4. | Is the User in your view, likely to inflict serious harm on him/herself or others? |
Yes
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No |
| 5. | Is care, treatment and rehabilitation services, in your view necessary for the protection of the User's financial interests or reputation? |
Yes
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No |
Section 10
Based on the abovementioned information my recommendation to the head of health establishment is that the User should─
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Section 11
I declare that I have personally informed the mental health care User of his/her rights, including his/her right to representation including the right to legal representation and/or Legal Aid, and the right to have his/her financial interests or reputation safeguarded and his/her right to have an administrator or curator appointed.
Comment:
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....................................................................................................................................
I ....................................................... (name of mental health care practitioner)
hereby declare that I have personally assessed ..........................................................
(name of mental health care user) at ...........................................................................
(name of health establishment) on ..................................................(date).
Signature: ..........................................................
Category of designated mental health care practitioner: ....................................................................
Registration number with relevant Council: ........................................................................................
Date: .........................................
Place: ........................................