Mental Health Care Act, 2002 (Act No. 17 of 2002)RegulationsGeneral RegulationsAnnexuresForm MHCA 27 |
ANNEXURE
FORM MHCA 27
DEPARTMENT OF HEALTH
GRANTING OF LEAVE OF ABSENCE TO A STATE PATIENT, ASSISTED OR INVOLUNTARY MENTAL HEALTH CARE USERS
(Section 45, 66 (1)(j) of the Act)
Surname of assisted or involuntary mental health care user ............................................................
First name(s) of assisted or involuntary mental health care user .......................................................
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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Residential address or custodian's name and address whilst on leave of absence:
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The User is : (mark with a cross)
State patient
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Assisted User
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Involuntary User
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Date of commencement of leave: .......................................
Due date of return from leave: ............................................
Name of health establishment where the User's mental health status will be monitored and reviewed:
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The User is to prevent him / herself to this health establishment every .................weeks / months to be monitored and his / her health status reviewed.
Name of health establishment(s) where care, treatment and rehabilitation will be provided and the nature of this:
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Conditions of behaviour which must be adhered to by the User:
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Name of psychiatric hospital where the User is to be admitted if he / she relapses and / or is not complying with the terms and conditions applicable to the leave:
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Print initials and surname: ...............................
Signature: .......................................................
(Head of health establishment)
Date: ...........................
Place: ...................................
Print initials and surname: .......................................
Signature: .................................................................
(custodian)
Date: ...............................
Place: .....................................