File Number

MH        /
            	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

MENTAL HEALTH ORDERS 

APPLICATION FORM FOR PSYCHIATRIC TREATMENT ORDER, COMMUNITY CARE ORDER AND/OR RESTRICTION ORDER
		
	For use by relevant person under Mental Health Act 2015		

1.	This application is about:                           			
Name:	_______________________   Gender:______________ DOB: ____________
 (You must complete and attach the information sheet for further details)

2.	The application is made by (Chief Psychiatrist or delegate or nominee of the Chief Psychiatrist):
Name: ________________________________________________________________
Position held: __________________________________________________________

3.	Why are you making this application? (Describe relevant events leading to the application)

MENTAL ILLNESS OR MENTAL DISORDER (Use the definitions set out in the glossary at the end of this form)
4.	The person has a mental illness  Yes       No       and/or a mental disorder    Yes       No

For mental illness: Describe how the illness impairs the person’s mental functioning, identify the areas of functioning that are affected by the illness and identify the  symptoms that characterise the illness and/or the behaviour that may be taken to indicate the presence of one or more of the symptoms. 

For mental disorder: Identify the disorder using the definition and describe how and to what degree the disorder affects the person
____________________________________________________________________
_____________________________________________________________________
______________________________________________________________________

ASSESSMENT (Set out details of your assessment supporting your opinion.)
5.	Date of most recent assessment ______________________

Current presentation: 

								
Mental State Examination including dates conducted:  

								
Relevant past history:	       

						
DECISION-MAKING CAPACITY
6.	Does the person, or can the person (with assistance if needed):
(a)	Understand when a decision about treatment, care or support needs to be made? 
Yes            No
(b)	Understand the facts that relate to the decision?  			Yes            No
(c)	Understand the main choices?			 		Yes            No
(d)	Weigh up the consequences of the main choices? 			Yes            No
(e)	Understand how the consequences affect the person? 		Yes            No
(f)	On the basis of (a)-(e) make the decision? 				Yes            No
(g)	Communicate the decision in whatever way the person can? 	Yes            No

Describe and explain your overall assessment referring to the factors above and to the principles of decision-making capacity set out in section 8 (see Glossary):

REFUSAL
7.	Does the person refuse to receive treatment, care or support; or, if the person has decision-making capacity, refuse to consent to treatment, care or support?   Yes    No

If yes, describe what the person does and/or says that constitutes refusal
___________________________________________________________________________________________________________________________________________

RISK OR DETERIORATION (answer on basis of likelihood if untreated)
8.	Is the person doing, or likely to do serious harm to themself or someone else because of the mental illness or mental disorder?                           Yes            No

If yes, explain your reasons for this opinion.

Is the person suffering, or likely to suffer serious mental or physical deterioration because of the mental illness or mental disorder?  	Yes            No

If yes, explain your reasons for this opinion.

TREATMENT
9.	What treatment, care or support is proposed? (If a treatment plan is prepared it may be attached to this form)

10.	Why or how will treatment care or support be likely to reduce harm, or deterioration, or result in an improvement to the person’s condition?

11.	Why can’t the treatment care or support be adequately provided with less restriction of the freedom of choice and movement of the person?

__________________________				
Signature 		 

_________________________
Full name of Applicant (relevant official or delegate or nominee of the Chief Psychiatrist)

Date: ______________

GLOSSARY
Section 10 Meaning of mental illness
In this Act:
mental illness means a condition that seriously impairs (either temporarily or permanently) the mental functioning of a person in1 or more areas of thought, mood, volition, perception, orientation or memory, and is characterised by—

(a) the presence of at least 1 of the following symptoms:
(i) delusions;
(ii) hallucinations;
(iii) serious disorders of streams of thought;
(iv) serious disorders of thought form;
(v) serious disturbance of mood; or
(b) sustained or repeated irrational behaviour that may be taken to indicate the presence of at least 1 of the symptoms mentioned in paragraph (a).

Section 9 Meaning of mental disorder
In this Act:
mental disorder—
(a) means a disturbance or defect, to a substantially disabling degree, of perceptual interpretation, comprehension, reasoning, learning, judgment, memory, motivation or emotion; but
(b) does not include a condition that is a mental illness.

Section 7 Meaning of decision-making capacity
For this Act, a person has capacity to make a decision in relation to the person’s treatment, care or support for a mental disorder or mental illness (decision-making capacity) if the person can, with assistance if needed—
(a) understand when a decision about treatment, care or support for the person needs to be made; and
(b) understand the facts that relate to the decision; and
(c) understand the main choices available to the person in relation to the decision; and
(d) weigh up the consequences of the main choices; and
(e) understand how the consequences affect the person; and
(f) on the basis of paragraphs (a) to (e), make the decision; and
(g) communicate the decision in whatever way the person can.

Section 8 Principles of decision-making capacity
(1) In considering a person’s decision-making capacity under this Act, the following principles must be taken into account:
(a) a person’s decision-making capacity is particular to the decision that the person is to make;
(b) a person must be assumed to have decision-making capacity, unless it is established that the person does not have decision-making capacity;
(c) a person who does not have decision-making capacity must always be supported to make decisions about the person’s treatment, care or support to the best of the person’s ability;
(d) a person must not be treated as not having decision-making capacity unless all practicable steps to assist the person to make decisions have been taken;
(e) a person must not be treated as not having decision-making capacity only because—
(i) the person makes an unwise decision; or
(ii) the person has impaired decision-making capacity under another Act, or in relation to another decision;
(f) a person must not be treated as having decision-making capacity to consent to the provision of treatment, care or support only because the person complies with the provision of the treatment, care or support;
(g) a person who moves between having and not having decision-making capacity must, if reasonably practicable, be given the opportunity to consider matters requiring a decision at a time when the person has decision-making capacity.
(2) A person’s decision-making capacity must always be taken into account in deciding treatment, care or support, unless this Act expressly provides otherwise.

(3) An act done, or decision made, under this Act for a person who does not have decision-making capacity must be done in the person’s best interests.

(4) In considering a person’s decision-making capacity under this Act, any approved code of practice under section 198 must be taken into account.