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

Regulations

General Regulations

Annexures

Form MHCA 06
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ANNEXURE

FORM MHCA 06

 

DEPARTMENT OF HEALTH

 

72-HOUR ASSESSMENT AND FINDINGS OF MEDICAL PRACTITIONER AND ANOTHER MENTAL  HEALTH CARE PRACTITIONER AFTER HEAD OF

HEALTH ESTABLISHMENT HAS APPROVED INVOLUNTARY CARE, TREATMENT AND REHABILITATION

(Section 34(1) of the Act)

 

 

Section 1

 

Surname of User .................................................................................

 

First name(s) of User  ...........................................................................

 

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

 

 

 

Gender:

 

 Male

 

Female

 

Occupation

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

Marital status:  

  S

 

M

 

D

 

W

 

 

Residential address:

 

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

 

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

 

 

Section 2

 

Date and time of the beginning of 72-hour assessment:  .........................................

 

Place of assessment : ..............................................................................................

 

 

Section 3

 

(a)        General physical health (To be completed by medical practitioners only):

 

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

 

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

 

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

 

(b)        Are there signs of injuries?  

 

Yes

No

 

If yes, please indicated whether you believe this is as a result of abuse?

Yes

No

 

If yes, was this abuse reported/investigated?      

 

Yes

No

 

(c)        Are there signs of communciable diseases?

 

Yes

No

 

 

If the answer to (b) or (c) is Yes, give further particulars:

 

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

 

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

 

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

 

 

Section 4

 

Past mental health history of the User (State dates and places):

 

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

 

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

 

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

 

 

Section 5

 

Mental health status of the User during the 72 hours assessment period:

 

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

 

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

 

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

 

 

Section 6

 

Type of illness (provisional diagnosis):

 

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

 

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

 

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

 

In my opinion the above-mentioned User—

 

has homicidal tendencies due to mental illness

 

Yes

No

 

has suicidal tendencies due to mental illness

 

Yes

No

 

is at risk to due to mental illness  

 

Yes

No

 

Section 7

 

Recommendation to head of health establishment—  an application for involuntary care:

 

Is the User capable of making an informed decision on the need to receive care, treatment and rehabilitation services?  

Yes

No

 

Does the User refuse to receive care, treatment and rehabilitation services?  

Yes

No

 

Is the User in your view, likely to inflict serious harm on him/herself or others?

Yes

No

 

Is the care, treatment and rehabilitation, in your view necessary for the User's financial interests and reputation?

Yes

No

 

Section 8

 

Based on the abovementioned information my recommendation to the head of health establishment is that the User should─

 

1. Receive voluntary care, treatment and rehabilitation services  

 

or

 

2. Receive assisted care, treatment and rehabilitation services

 

or

 

3. Continue to receive involuntary in-patient care, treatment and rehabilitation services

or

 

4. Receive involuntary out-patient care, treatment and rehabilitation services

or

 

5. Be discharged from the Mental Health Care Act

 

or

 

Section 9

 

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 and/or reputation safeguarded.

 

Comment: .............................................................................................................

 

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

 

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

 

 

Section 10

 

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

 

Registration Category: ........................................................................................

 

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

 

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

 

 

Category of designated mental health care practitioner for example 'nurse', psychologist' or 'medical pratitioner' :

 

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

 

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

 

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