Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 24 |
ANNEXURE
FORM MHCA 24
DEPARTMENT OF HEALTH
TRANSFER OF STATE PATIENTS AND MENTALLY ILL PRISONERS BETWEEN DESIGNATED HEALTH ESTABLISHMENTS
(Sections 43(1) and 54(1) of the Act)
Surname of state patient / mentally ill prisoner ......................................................
First name(s) of 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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The above state patient or mentally ill prisoner shall be transferred:
From: ......................................................................(name of health establishment)
To: ...........................................................................(name of health establishment)
Reasons to transfer:
.................................................................................................................
..................................................................................................................
..................................................................................................................
..................................................................................................................
Print Initials and Surname: .......................................
Signature: ..................................................................
(Head of provincial department)
Date: ...................................
Place: .......................................
Concurrence of Head of Province to where the state patient or mentally ill prisoner is to be transferred must be obtained where inter-provincial transfers are contemplated.
Signature: .....................................................
(Head of provincial department)
Date: ....................................
Place: .........................................
(Copy to be forwarded to official curator ad litem, head of national department and head of health establishment to where state patient or mentally ill prisoner is transferred)