File Number

MH       /	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

INFORMATION SHEET 

TO BE ATTACHED TO EVERY 
APPLICATION FORM
		
	This information must be attached to ANY
application to ACAT for orders under 
the Mental Health Act 2015		

Name of person ________________________________	Gender: _____________ DOB: ____________
Home address

Current address (if different)

Phone (h)________________ Email  ___________________________ 

Does the person have a current Advance Agreement?	         Yes	   No	         Don’t know
If so, what date was this made __________________
Copy attached 			Yes		No

Does the person have a current Advanced Consent Direction?	         Yes	   No	      Don’t know
If so, what date was this made __________________
Copy attached 			Yes		No
Details of People who must be notified/consulted
If the person is a child – each person with parental responsibility for the child
Name	________________________________		Ph: _____________________
Email address: ___________________________		Ph: _____________________
Name	________________________________		Ph: _____________________						
Name	________________________________		Ph: _____________________
Email address: ___________________________		Ph: _____________________
Name	________________________________		Ph: _____________________

The Guardian
Name	________________________________		Ph: _____________________
Email address: ___________________________		

The Attorney (under EPOA)
Name	________________________________		Ph: _____________________
Email address: ___________________________		
Health Attorney 
Name	________________________________		Ph: _____________________
Email address: ___________________________		

Nominated Person
Name	________________________________		Ph: _____________________
Email address: ___________________________
The Carer 
Name	________________________________		Ph: _____________________
Email address: ___________________________  

This information was completed on _______________ (date)
Name: ________________________________________________
Phone: _______________________		  Email:  ______________________________________