File Number

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	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

MENTAL HEALTH ORDERS- APPLICATION FORM
		
	For use by professional person
*Mental Health (Treatment and Care) Act 1994		

I											

Of											

Wish to apply for:

	Psychiatric Treatment Order
	Duration of Order Sought			; or [Complete parts 1 – 10]

	Community Care Order 
	Duration of Order Sought			; and/or [Complete parts 1 – 10]

	Restriction Order – Content to consider:
	[please list]

											

	Electro Convulsive Therapy  [Second Independent Psychiatric opinion must be attached]
	Expiry date of Section 28 order:		/	/	

	Emergency Electro Convulsive Therapy 

	Revocation of Restriction Order

 	I ALSO APPLY FOR AN ASESSMENT ORDER TO SUPPORT THIS APPLICATION

in respect of:

Mr/Mrs/Miss/Ms									
				(Given Names)		(Surname)

Address:										

								Postcode		

Date of Birth:		/	/	

Date of Application: 		/	/	

Is the said person under 18 years	 Yes		 No
[If yes please provide details of parent/s or Legal Guardian]

Name:											

Address:							Postcode:		

Telephone: (H)				(W)					

Is the person subject to a guardianship or management of property order? 
					  Yes		 No

[If yes, please provide details of Guardian and/or Manager]

Name:											

Address:							Postcode:		

Telephone: (H)				(W)					

Is the said person currently an inpatient?   Yes   No

  PSU	  Calvary OPMHIU

Is this application abridging time limits established by the legislation? If so, 
please give reasons

											

I DO SOLEMNLY AND SINCERELY DECLARE THAT:

1.	I believe on reasonable grounds, that the said person:

	(a)	is unable because on mental dysfunction or mental illness-

   		(i)	to make reasonable judgements 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]

2.	Please set out your reasons, in detail, to support your statement in Part 1.

											

											

											

											

3.	Does the said person have the capacity to give informed consent to treatment, care and support?	 Yes		 No

	Diagnosis:

											

											

4.     History of Present Illness and Present Mental Health Status Examination:
        [Date last seen to be included]

											

											

											

											

5.	Previous Mental Health History (including treatment):

											

											

											

											

											

											

6.	Current Medication:

											

											

7.	Proposed Treatment Plan: [detailing psychological/family/medication strategies,
	likely benefits and risks validating least restrictive option]
	{If applying for Electro Convulsive Therapy – Justification for same, as appropriate, including 2nd opinion}

											

											

											

8(a)	Who is to prescribe and administer treatment?

											

(b)	How, when and where is the respondent to receive treatment?
	[outline plans for transition to community care – indicate Carer’s view where appropriate]

											

											

(c)	Is the said person currently assigned a case manager?  If not, is a case
	manager to be assigned?
	[Please state details (including the name and location of the case manager)]

											

(d)	Are any other services required?
	[eg: education, rehabilitation, counselling care and support etc]

											

											

(e)	Does the said person require supported accommodation?
	[If so, please give details]

											

9.	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 [go to Part 10]	 No [go to Part 11]

10.	If yes, please provide grounds to support your statement in Part 9.

											

11.	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 add attachment if insufficient space].

(i)	Name

	Address

	PH:  				(H)					(W)

(ii)	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 declaration]

Declared at Canberra
The		day of			.

Before me:								
(Signature and title of person before whom the declaration is made)