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: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________

Email address: ___________________________	

Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________

Email address: ___________________________	

The Guardian
Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________
Email address: ___________________________		
The Attorney (under EPOA)
Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________
Email address: ___________________________	
Health Attorney 
Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________
Email address: ___________________________			
Nominated Person
Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________
Email address: ___________________________	
The Carer 
Name	________________________________		Ph: _____________________
Postal address: _________________________________________________________	
______________________________________________________________________
Email address: ___________________________	
This information was completed on _______________ (date)
Name: ________________________________________________
Phone: _______________________		  Email:  ______________________________________