New South Wales Consolidated Regulations New South Wales Consolidated Regulations(Clause 3 (1))
(Clause 4 (a) and (b))
( Mental Health Act 2007 , section 27 (a), 27 (b) or (c))
Medical report as to mental state of a detained person
This report is made as:
□ a certificate of the opinion of an authorised medical officer after examination of a person under section 27 (a) of the Act (initial examination),
□ advice by a medical practitioner to an authorised medical officer under section 27 (b) or (c) of the Act (further examination)(tick whichever is appropriate)
I, the undersigned, a registered medical practitioner, on [date] personally examined [patient’s name] a person detained at [mental health facility].
In my opinion, [patient’s name]:
□ is not a mentally ill or mentally disordered person,
□ is a mentally ill person,
□ is a mentally disordered person.(tick the one box that is appropriate)
The basis for my opinion is as follows:
(This report can be continued on a separate page, if necessary)
Name of registered medical practitioner:
Qualifications as a psychiatrist (if applicable)
[Date]
Note: This report is for the use of a legal tribunal and therefore should not be written in technical medical language.)
(Clause 5)
( Mental Health Act 2007 , section 76 (3))
Mental health inquiry-
Mental health facility
Address
Notice of proceedings before Magistrate
Dear
I wish to advise you that [patient’s name] is at present a patient at this mental health facility under the provisions of the Mental Health Act 2007 .
On [date] at approximately [time] a visiting Magistrate will hold an inquiry at [location] to consider whether or not further detention for the purpose of treatment is warranted.
You are invited to attend this inquiry. With the permission of the patient and the Magistrate, any person at all may represent the patient. However, the patient will be legally represented unless the patient decides that he or she does not want to be. Should it be necessary, a competent interpreter will be available to assist.
If the Magistrate considers further detention is warranted the Magistrate will also consider whether or not the patient is able to manage his or her affairs. If the Magistrate considers that the patient is able to do so, then the patient will continue to do so. If the Magistrate is not satisfied that the patient can manage his or her affairs, then an order will be made that the Protective Commissioner manage the patient’s affairs.
If the patient does not agree that his or her affairs should be managed by the Protective Commissioner, the patient may appeal to the Supreme Court or the Administrative Decisions Tribunal.
If you have any questions, please feel free to discuss them with the patient’s doctor or social worker. Contact may be made by telephoning [telephone number].
Yours faithfully,
[Date]
(Clause 7)
( Mental Health Act 2007 , Schedule 2, clause 5)
Summons
Inquiry under
Mental health facility
Address
To:
A Magistrate will be holding a mental health inquiry under the Mental Health Act 2007 in relation to [patient’s name].
The inquiry will be held at [time] on [date] at the above address.
You are required:
□ to attend the inquiry as a witness
□ to attend the inquiry and to produce the following documents:(tick one or both boxes)
You are entitled to receive reasonable costs, including any loss of earnings incurred through compliance with this summons.
Should you fail or refuse to comply with this summons properly served, you may be guilty of an offence under the Mental Health Act 2007 .
If you are required to attend the hearing only to produce documents, it is sufficient compliance with this summons if those documents are delivered toat [address] on or before [date].
[Name]
(Clause 9 (1) (a))
( Mental Health Act 2007 , section 44 (2))
Appeal by patient against refusal to discharge
The Registrar
Mental Health Review Tribunal
My name is [name].
I am an involuntary patient at [name of mental health facility].
I have applied to an authorised medical officer for discharge under section 44 (1) of the Mental Health Act 2007 .
I want to appeal to the Mental Health Review Tribunal against the authorised medical officer’s:
□ refusal to discharge me
□ failure to make a determination on my application for discharge within 3 working days after I made the application.(Tick one box only)
[Date]
(Clause 9 (2) (a))
( Mental Health Act 2007 , section 44 (2))
Appeal by a person other than the patient against refusal to discharge a patient
This appeal relates to [patient’s name] who is an involuntary patient at [name of mental health facility].
An application was made to an authorised medical officer for discharge of the patient under section 44 of the Mental Health Act 2007 .
My name is [name of appellant].
I am:
□ the applicant for discharge of the patient
□ a person appointed by the patient.(Tick one box only)
I want to appeal to the Mental Health Review Tribunal against the authorised medical officer’s:
□ refusal to discharge the patient
□ failure to make a determination within 3 working days after the application for discharge of the patient.(Tick one box only)
[Date]
(Clauses 13 and 14)
( Mental Health Act 2007 , sections 91, 93 and 96)
Information and consent-electro convulsive therapy
The treatment is recommended where the alternative forms of treatment have either not had the desired result or would work too slowly to be effective in a particular case.
The treatment will take the following form:(a) You will be given a brief general anaesthetic. This involves giving a drug to relax the muscles. The anaesthetist will normally give the anaesthetic by means of intravenous injection.(b) While you are anaesthetised, another medical practitioner will use medical apparatus designed to pass a modified electrical current for a few seconds through your brain, with the intention of affecting those parts concerned with emotion and thought.(c) While the current is passing, the anaesthetic will prevent you from feeling anything and will also prevent your body from moving more than slightly.(d) Treatment may be given 2 or 3 times a week.(e) A course of treatment will generally involve up to 12 treatments but, on some occasions, more treatments will be required. Any queries you have in relation to the number of treatments you may need can be raised with your doctor.
Possible benefits of treatment Benefits depend on the symptoms of the conditions for which treatment is given. Relief may be obtained from symptoms of depression, agitation and insomnia.
Possible alternative treatments Other treatments may also be suitable for your condition. Any queries you have in relation to these can be discussed with your doctor.
A written explanation of the alternative treatments available in relation to your condition is attached.
Possible complications of treatment Some patients notice a difficulty with their memory of recent events which almost invariably clears up within a month of receiving the last treatment. Some patients experience a headache or a brief period of confusion, or both, on awakening after the anaesthetic. Otherwise, because the treatment and anaesthetic are very brief and present no significant stress to the body, serious complications are uncommon. All general anaesthetics carry some risk.
Consent to treatment This treatment cannot be carried out without your consent (see Part 2 below), unless you are an involuntary patient at the mental health facility. If you are an involuntary patient, the treatment can only be carried out without your consent after a full hearing before the Mental Health Review Tribunal.
Before giving this consent you may ask your doctor any questions relating to the techniques or procedures to be followed. You may also withdraw your consent and discontinue this treatment AT ANY TIME.
Legal and medical advice You also have the right to get legal advice and medical advice before you give your consent.
Disclosure of financial relationshipItem A To be completed by the person proposing the administration of the treatment.(a) I declare that there is no financial relationship between me and the mental health facility or institution in which it is proposed to administer the treatment.(OR)(b) I declare that the following is a full disclosure of the financial relationship between me and the mental health facility or institution in which it is proposed to administer the treatment:[Date]
Item B To be completed by the medical practitioner who proposes to administer the treatment (unless that medical practitioner is also the person who completed Item A, in which case this Item need not be completed).(a) I declare that there is no financial relationship between me and the mental health facility or institution in which it is proposed to administer the treatment.(OR)(b) I declare that the following is a full disclosure of the financial relationship between me and the mental health facility or institution in which it is proposed to administer the treatment:[Date]
I, [name in full] consent to
being treated with electro convulsive therapy.
I ACKNOWLEDGE that I have read/have had read to me Part 1 of this Form, and
that I understand the information it contains.
I UNDERSTAND that I am free at any time to change my mind and withdraw from
the course of treatment if I so desire.
[Date]
I, [name
in full] consent to being treated with electro convulsive therapy.
I ACKNOWLEDGE that I have read/have had read to me Part 1 of this Form, and
that I understand the information it contains.
I UNDERSTAND that I am free at any time to change my mind and withdraw from
the course of treatment if I so desire.
I UNDERSTAND that my consent will be reviewed by the Mental Health Review
Tribunal.
[Date]
I certify that all matters dealt with in this Form
have been orally explained to the person in respect of whom treatment is
proposed and have been so explained in a language with which that person is
familiar.
[Date]
(Clause 15)
( Mental Health Act 2007 , section 97)
Register of electro convulsive therapy
The register of electro convulsive therapy must set out the following information relating to each administration of treatment:
(a) the date of the treatment,
(b) the classification of the patient,
(c) the section of the Mental Health Act 2007 under which consent was given,
(d) details of the patient, namely the patient’s name, age, sex and medical record number,
(e) the ward in which the treatment was administered,
(f) details of the anaesthetic used,
(g) the name of the anaesthetist,
(h) a psychiatric and medical diagnosis,
(i) the duration of the treatment,
(j) the voltage used,
(k) the name of the medical officer in charge of administering the treatment,
(l) the name of any assistant to the medical officer,
(m) the name of any registered nurse,
(n) the placement of electrodes.
The register of electro convulsive therapy may include further remarks or observations in relation to any treatment registered on it.
(Clause 22)
( Mental Health Act 2007 , section 157 (1))
Summons
Mental Health Review Tribunal
To:
The Mental Health Review Tribunal will be hearing matters in relation to [name of patient].
The hearing will take place at [time] on [date] at [address].
You are required:
□ to attend the hearing as a witness
□ to attend the hearing and produce the following documents:(Tick one box only)
You are entitled to receive reasonable costs, including any loss of earnings incurred through compliance with this summons.
Should you fail or refuse to comply with this summons, properly served, you may be guilty of an offence under the Mental Health Act 2007 .
If you are required to attend the hearing only to produce documents, it is sufficient compliance with this summons if those documents are delivered toat [address] on or before [date].
[President/Deputy President
Mental Health Review Tribunal]
(Clause 47)
( Mental Health Act 2007 , section 165 (2))
Oath of assessor
I, [name], do swear that I will well and truly advise and assist, without fear or favour, affection or ill will, the Supreme Court of New South Wales as an assessor in any matter coming before that Court pursuant to the provisions of the Mental Health Act 2007 .
(Clause 48)
( Mental Health Act 2007 , section 196 (2) (l))
Particulars of involuntary referrals
The report must include:
(a) the name of the mental health facility,
(b) the name and contact number of the person by whom the report was prepared.
The report must include the following information about each patient:
(a) the patient’s medical record number (or MRN),
(b) the patient’s date of birth,
(c) the patient’s country of birth,
(d) whether an interpreter was required for the patient and, if so, in what language,
(e) the date the person was taken to the mental health facility or the date the patient was reclassified to involuntary,
(f) the method of referral of the person, that is:(i) by doctor’s certificate under section 19 of the Act,(ii) by the police under section 22 of the Act,(iii) by an ambulance officer under section 20 of the Act,(iv) because of a breach of a community treatment order, under section 58 of the Act,(v) by a primary carer, relative or friend under section 26 of the Act,(vi) in accordance with an order under section 33 of the Mental Health (Forensic Provisions) Act 1990 , under section 24 of the Mental Health Act 2007 ,(vii) following an order under section 23 of the Act for medical examination or observation and an authorised doctor’s certificate under section 19 of the Act,(viii) by being reclassified from a voluntary patient to an involuntary patient,
(g) whether the person was admitted after examination,
(h) whether on admission the patient was classified as:(i) voluntary,(ii) involuntary, mentally ill,(iii) involuntary, mentally disordered.
(Clause 49)
( Mental Health Act 2007 , section 196 (2) (l))
Particulars of persons presented to a Magistrate
The report must include:
(a) the name of the mental health facility,
(b) the name and contact number of the person by whom the report was prepared.
The form must include the following information about each person presented to the Magistrate on the date to which the form relates:
(a) the medical record number of the person,
(b) whether an interpreter was required for the person and, if so, in what language,
(c) which of the following decisions or determinations was made:(i) adjournment,(ii) discharge or deferred discharge,(iii) reclassify from an involuntary patient to a voluntary patient,(iv) involuntary patient order,(v) community treatment order.
(Clause 50)
( Mental Health Act 2007 , Division 3 of Part 2, Chapter 3)
Order or direction of magistrate-mental health inquiry
Mental health facility
Address
Date
(Complete Part 1 or Part 2 only)
Part 1 Order or direction
I have today ordered or directed that [patient’s name] (who was brought before me under section 34 of the Mental Health Act 2007 ):
□ must be discharged from the mental health facility
□ must be discharged from the mental health facility into the care of [name]
□ must be detained as an involuntary patient until no later than [date] for further observation or treatment, or both
□ must be made subject to a community treatment order(Tick one box only)
The reasons for my order or direction (as required by clause 9 of Schedule 2 to the Act) are annexed to this form.
(OR)
Part 2 Order for adjournment
I have today ordered the adjournment of the inquiry in relation to [patient’s name] (who was brought before me under section 34 of the Mental Health Act 2007 ) for a period of [number of days] days.
Name of Magistrate
The reasons for my order (as required by clause 9 of Schedule 2 to the Act) are annexed to this form.