Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 19 |
ANNEXURE
FORM MHCA 19
DEPARTMENT OF HEALTH
REQUEST BY HEAD OF HEALTH ESTABLISHMENT TO REVIEW BOARD TO TRANSFER MENTAL HEALTH CARE USER / STATE / MENTALLY ILL PRISONER
| (a) | an assisted or involuntary mental health care user in terms of section 39(1) of the Act to maximum security facilities; |
| (b) | a State patient between designated health establishments in terms of section 43 of the Act; or |
| (c) | a mentally ill prisoner between designated health establishments in terms of section 54(2) of the Act. |
Surname of mental health care user/state patient/mentally ill prisoner ..................................................
First name(s) of mental health care user/state patient/mentally ill prisoner ............................................
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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Health establishment from where the request is made: ...........................................................
State clearly the reason(s) for the request: ...............................................................................
.................................................................................................................................................
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Has the User previously absconded or attempted to abscond?
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Yes |
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No |
Explain circumstances:
.............................................................................................................................................
.............................................................................................................................................
Has the User inflicted harm on others at the health establishment?
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Yes |
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No |
.............................................................................................................................................
..............................................................................................................................................
In your opinion is the User likely to inflict harm on others in the health establishment? |
Yes |
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No |
...............................................................................................................................................
...............................................................................................................................................
Explain:
...............................................................................................................................................
...............................................................................................................................................
Other reason(s) for making the request:
..............................................................................................................................................
..............................................................................................................................................
Print initials and surname: ....................................................................
Signature: .............................................................................................
(Head of health establishment)
Date: ......................................
Place: .............................................