SCHEDULE FORM 1

MENTAL HEALTH REGULATIONS 1995 (reg. 5(a)

 ORDER FOR ADMISSION AND DETENTION IN AN APPROVED TREATMENT CENTRE (S. 12(1))

 To: The Director,.......................................................... (approved treatment centre)

1. I have at *am/pm on this date__/__/__    (time) __:__

 completed my examination of ................................................... (full name in block letters)

of ............................................................................. (address in block letters)

 sex* male / female, date of birth__/__/__

  2. The above person *is/is not already a voluntary patient in the treatment centre.

 3. As a result of my examination I am satisfied-

(a) that the above person has a mental illness that requires immediate treatment; and

(b) that the treatment is available in the above centre; and

(c) that the person should be admitted (if not already a patient) and detained in the centre-

    (i) in the interests of *his/her health and safety; *and/or

    (ii) for the protection of other persons.

4. The grounds on which I have formed my opinion are as follows (additional reports *are/are not attached):

5. I make an order for-

(a) the immediate admission of the person to the above treatment centre (strike this out if the person already is a voluntary

patient in the centre); and

(b) the detention of the person in the above treatment centre.

Name (block letters) Date __/__ /__

Address (block letters) Time *am/pm

Signature (Medical Practitioner)

*Cross out whichever is not applicable.