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ANNEXURE

FORM MHCA 13A

DEPARTMENT OF HEALTH

PERIODICAL REPORT ON MENTAL HEALTH CARE USER (ASSISTED/INVOLUNTARY USER/MENTALLY ILL PRISONER)

(Sections 30(2), 37(2) and 55(1) of the Act)

Section 1: Biographical information

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

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

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

Gender:

Male

Female

The User is an: (mark with a cross)

Assisted User

Involuntary User

Mentally ill prisoner

Name of health establishment concerned: ............................................................................

Registration number (if any): .................................................................................................

Date of first admission of mental health care user under this section: ....................................

Section 2: Assessment

Mental health status: (Short statement of the mental health status before and since admission, since the last report, and the present condition, with special reference to any symptom indicating homicidal, suicidal or dangerous tendencies)

Before admission:

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

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

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

Since admission / previous periodical report:

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

Physical condition of User:

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

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

Diagnosis:

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

Section 3: Clinical management, treatment and rehabilitation plan

Present treatment programme to be followed, including psycho-pharmacological, ECT, occupational therapy or psychotherapy social work intervention with family, leave of absence to family, etc):

Medical:

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

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

Psychological:

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

Social (including the safeguarding of the User's financial interests):

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

Occupational:

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

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

Physiotherapy (if required):

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

Family contacts:

Personal

Correspondence

Regular

Seldom

Never

In the case of never, what has been done to trace to family?

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

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

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

Section 4: Recommendation in terms of Section 30 or 37 or 55(1)

(a)	The User is suffering from a mental illness or severe/profound mental diability and requires care, treatment and rehabilitation services for his/her health or safety or the health or safety of other people or for the protection of the financial interests or reputation of the User;

(b)	The User is currently incapable of making an informed decision on the need for the care, treatment and rehabilitation services

and

(c)	The User is refusing

not refusing

care, treatment and rehabilitation services

Should the User status remain unchanged?

Yes

Briefly motivate:

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

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

If the User is an involuntary impatient, should he / she be transferred to involuntary outpatient care?

Yes

Briefly motivate:

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

Please add additional paper if required, as this is extremely important:

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

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

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

Print initials and surname of assessing practitioner: ..............................

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

(assessing practitioner)

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

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

Section 5: Instructions and remarks

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

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

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

(Head of health establishment)

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

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

'(Original to Review Board and copy of report in case of mentally ill prisoner to relevant magistrate, administrator, if appointed, and head of relevant prison'

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

Regulations

General Regulations

Annexures

Form MHCA 13A