File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

APPLICATION- MENTAL HEALTH
		
	For use by Layperson
* Mental Health (Treatment and Care) Act 1994

I, ___________________________________________________________________ 
(Applicant’s Name)

of ___________________________________________________________________
(Applicant’s Address)

Telephone number:  (w) _____________________ (h) _______________________

wish to apply for an order of the ACT Civil & Administrative Tribunal in relation to:

Mr/Mrs/Miss/Ms  _____________________________________________________
                     				 (Person’s  Full Name)
		
of ___________________________________________________________________
(Person’s Address)

Telephone number:  (w) ______________________ (h) ______________________

Date of Birth ______/_____/_____ .

Is the said Person under the age of 18 years?  Yes   No
[If yes, please provide details of Parent/s or Legal Guardian]

Name _______________________________________________________________

Address _____________________________________________________________

PH: 	______________________(H)  	     _____________________ (W)

Is the said Person under a Guardianship or/and a Management of Property Order? 
 Yes   No 
[If yes, please provide details of the Guardian and/or Manager]

Name _______________________________________________________________

Address _____________________________________________________________

PH: 	______________________(H) _____________________ (W)_______________

I DO SOLEMNLY AND SINCERELY DECLARE THAT:

I believe on reasonable grounds, that the said Person:

 	(a)	is unable because of mental dysfunction or mental illness-
		(i)	to make reasonable judgments about matters relating to 			his/her health or safety; or
		(ii)	to do anything necessary for his/her health or safety;

		and as a result, the said Person’s health or safety is, or is likely to 		be, substantially at risk; 	
OR

	(b) 	is or is likely to be, because of mental dysfunction or mental illness, 		to do serious harm to others.
(Tick whichever applies)

Please set out your reasons in detail to support the above. 
[Attach a separate sheet if necessary]
_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Does the said Person have a history of mental illness/mental dysfunction: 
 Yes   No
[If yes, please provide details of diagnosis and treating doctor (if known):]
___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Is the said Person under supervision of a case manager?  Yes   No
[If yes, please provide details (if known)]
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List any other service agencies that have been involved with the said Person:
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Would the risk to the said Person’s health or safety or the danger to the community increase substantially should the said Person appear before the Tribunal?	
 Yes   No

If yes please provide grounds  in support of the above.
_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The following person/s would be able to assist the Tribunal or are otherwise interested in the health and welfare of the said Person.
 [Please provide name address and contact telephone numbers.]

(i)  	Name	_______________________________________________________________
	Address	_______________________________________________________________
	PH: 	____________________ (H)  	     ____________________ (W)
(ii) 	 Name			_______________________________________________________________
	Address		_______________________________________________________________
	PH: 	____________________ (H)  	    _____________________ (W)
(iii)  	Name			_______________________________________________________________
	Address		_______________________________________________________________
	PH: 	____________________ (H)  	     ____________________ (W)
(iv) 	 Name		
	_______________________________________________________________
	Address	
	_______________________________________________________________
	PH: 	___________________ (H)  	                _____________________ (W)

And I make this solemn declaration by virtue of the Commonwealth’s Statutory Declarations Act 1959, and subject to the penalties provided by that Act for the making of false statements in statutory declarations, conscientiously believing the statements contained in this declaration to be true in every particular.

_______________________________________
                                   		    	      (Signature of person making the declaration)		

Declared at Canberra, 
the _____ day of _____________,
______.
Before me:	________________________________________
(signature and title of person before whom the declaration is made)