File Number
 
MH        /	ACT CIVIL AND ADMINISTRATIVE TRIBUNAL

MENTAL HEALTH ORDERS 

APPLICATION FOR A FORENSIC MENTAL HEALTH ORDER		
	  
  Mental Health Act 2015		

1.	This application is about:                           			
Name:	_________________________________________  DOB:  ____________________
 (Information sheet with further details must be attached)

2.	The application is made by:
Name:									
Phone:                                           Email:   
Position held:
								
3.	The subject person is (please tick relevant box)
(a)	A detainee
(b)	A person serving a community-based sentence
(c)	A person released on parole
(d)	A person released on licence under the Crimes (Sentence Administration) Act 2005, section 299,
(e)	A young detainee
(f)	A young offender

4.	Does the person have a mental illness?          Yes          No    or a mental disorder?         Yes          No

5.	Set out your assessment of the person’s mental state 
Current presentation:

Mental State Examination including dates conducted:

Relevant past history:

6.	Does the person consent to treatment?  Yes    	No

7.	Is the person doing, or likely to do serious harm to themself or others? Yes 	No
	
8.	If yes, what is the person doing or likely to do?

9.	Is the person suffering or likely to suffer serious mental or physical deterioration if not involuntarily treated?  Yes         No 

10.	If yes, describe the deterioration and why you believe it will occur.

11.	Why does the applicant believe the person has or is likely to seriously endanger public safety?

12.	How will treatment, care or support be likely to reduce the harm, deterioration or endangerment to themselves, or others, or public safety, or the likelihood of these things?

13.	How will treatment, care or support result in an improvement in the person’s condition?

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

15.	Is there anything to do with the application process that is likely to increase the risk to the person’s health or safety, or the risk of serious harm to others?  Yes     	No

16.	If yes, what is the basis for your belief?

Pursuant to section 94(3) of the Mental Health Act 2015, this is my written statement.

__________________________		_________________________                 ______________
Full name of relevant official		Signature 				Date

Forensic Treatment Plan and Location Determination is attached.  Approved form number 65464
Information sheet attached