Mental Health Care Act, 2002 (Act No. 17 of 2002) Regulations General Regulations Annexures Form MHCA 15

 

ANNEXURE

FORM MHCA 15

 

DEPARTMENT OF HEALTH

 

APPEAL TO REVIEW BOARD AGAINST DECISION OF HEAD OF HEALTH ESTABLISHMENT ON ASSISTED - OR INVOLUNTARY MENTAL HEALTH

CARE, TREATMENT AND REHABILITATION

(Section 29(1) and 35(1) of the Act)

 

 

Details of User

 

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

 

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

 

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

 

 

 

Residential address:

 

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If No to the above:

 

Surname of appellant  ...............................................................................

 

First name(s) of appellant   ........................................................................

 

Contact number of appellant  .............................................. or estimated age .............

 

 

Residential address:

 

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

 

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

 

 

Relationship between appellant and mental health care user:  (mark with a cross)

 

 

 

 

 

 

 

 

 

Grounds for the appeal:

 

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Facts on which the appeal is based:

 

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I, the undersigned wish to have representation/Legal Representation / Legal Aid for myself or on behalf of ................................................(put in a tick box for yes or no)

 

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

 

 

 

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

(appellant)

 

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

 

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