File Number
        
MH      /	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

ASSESSMENT ORDER
APPLICATION FORM 
		
	Mental Health Act 2015		

1.	This application is about:                           			
Name:	_______________________   Gender:______________ DOB: ____________
 (You must provide further details by completing and attaching the Information Sheet)

2.	The application is made by: 
Name: ________________________________________________________________
Position held: __________________________________________________________
Phone: _________________________ Email: __________________________________

Applicant’s relationship to Person:
	Self
	Other – (Carer, Relative, Friend, Health Professional)
	Referring Officer (s35, Mental Health Act 2015)

3.	Do you believe the person has a mental illness or mental disorder?  Yes  	         No  

If yes, state the reasons for your belief.

4.	Why  are you making this application

5.	Provide information about past mental health history if known

6.	Is there actual or potential risk to the person’s health or safety ?(indicate below)

(i)	Health	Yes    	No    	Not known 
(ii)	Safety	Yes    	No    	Not known 

If yes, what is the risk?

7.	Is the person causing or likely to cause serious harm to others?   Yes    	  No  	  Not known

If yes, explain why.

8.	Do you believe that the application process is likely to substantially increase the risk to the other person’s health or safety or the risk of serious harm to others?  
Yes    	No  

If yes, explain why you have this belief.	

__________________________		_________________________
Full name of applicant			Signature 

Date:

Information sheet attached.