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ANNEXURE

FORM MHCA 36

DEPARTMENT OF HEALTH

ASSESSMENT OF MENTAL HEALTH STATUS OF PRISONER FOLLOWING REQUEST FROM HEAD OF A PRISON AND / OR MAGISTRATE

DISCHARGE OF A STATE PATIENT

(Section 50(2) or 52 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: ..................................................................................................

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

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

Prison number: ...........................................................................................................

Date of examination: .......................... Place of examination: ...................................

Category of designated mental health care practitioner: ..............................................

Physical health status (filled in only by practitioner qualified to conduct physical examination)

(a)	General physical health:

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

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

(b)	Are there signs of injuries?

Yes

or No

(c)	Are there signs of communicable disease?

Yes

or No

If the answer to (b) or (c) is Yes, give further particulars:

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

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

Reports facts on previous observations of mental illness (state who provided this information):

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

Facts concerning the mental condition of the prisoner which were observed on previous occasions (State dates and places):

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

Mental health status of the User at the time of the present examination:

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

Type of illness (provisional):

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

In my opinion the above-mentioned prisoner—

has homicidal tendencies:

Yes

or No

has suicidal tendencies:

Yes

or No

is dangerous:

Yes

or No

Recommendation to head of prison

The prisoner is mentally ill and requires care, treatment and rehabilitation:

Yes

or No

In my opinion the prisoner can be given care, treatment and rehabilitation with the prison and / or in a prison hospital:

Yes

or No

In my opinion the mental illness is of such a nature that the prisoner should be sent to a psychiatric hospital for care, treatment and rehabilitation:

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

Plan for care, treatment and rehabilitation for prisoner:

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

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

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

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

(mental health care practitioner who assessed mental health status of prisoner)

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

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

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

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Form MHCA 36