Regulations > General Regulations > Annexures 1-46

ANNEXURE

FORM MHCA 34

DEPARTMENT OF HEALTH

APPLICATION TO REGISTRAR OF THE HIGH COURT FOR AN ORDER AMENDING THE CONDITIONS / REVOKING THE CONDITIONAL

DISCHARGE OF A STATE PATIENT

(Section 48(5) 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:

Address: ....................................................................................................................

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

Nature of charge: .......................................................................................................

Residential Address: ..................................................................................................

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

I hereby request that the conditional discharge of the above state patient be amended or revoked.

The above state patient has not complied with the following terms and conditions of his/her conditional discharge (explain)

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

and his / her mental heart status has deteriorated (explain)

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

(if applicable) I recommend that the terms and conditions of the discharge be amended along the following lines:

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

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

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

(head of health establishment)

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

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

(Copy to be forwarded to the official curator ad litem and national department)

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