Regulations > General Regulations > Annexures 1-46

ANNEXURE

FORM MHCA 29

DEPARTMENT OF HEALTH

APPLICATION FOR DISCHARGE OF STATE PATIENT TO JUDGE IN CHAMBERS (WHERE APPLICANT IS NOT AN OFFICIAL CURATOR

AD LITEM OR ADMINISTRATOR

(Sections 47(2)(e) of the Act)

Surname of state patient.........................................................................................

First name(s) of state patient ..................................................................................

File No. (if known) ...................................................................................................

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

Gender:

Male

Female

Occupation

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

Marital status:

Residential address: .................................................................................................

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

Charge against state patient: ....................................................................................

Person making application (mark with a cross):

State patient him / herself

Head of health establishment

Responsible medical practitioner

Spouse

Associate

Next of kin

Other

Reasons for application:

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

Has an application been made for discharge of state patient within the preceding 12 months by any application other than an official curator ad litem?

Yes

If Yes provide details of the status of that application (and no need to proceed further with this form):

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

Report from psychologist (if available):

Yes

In your opinion does the official curator ad litem have a conflict of interest with the state patient?

Yes

Give reasons:

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

Supply proof that a copy of the application has been given to the official curator ad litem concerned.

Where the applicant is an 'associate' state the nature of the substantial or material interest in the state patient:

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

Attach all reports you have available relevant to this application.

Provide details of any prior application for discharge that you are aware of:

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

Print initials and surname: ..........................................

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

(Applicant)

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

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

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

Regulations

General Regulations

Annexures

Form MHCA 29