MENTAL TREATMENT: SUBSIDIARY LEGISLATION

    In the ……………………………………… Subordinate Court of ………………………… The petition of ……………………………………. of …………………………………………..

    1. I hereby make application for the reception into a Mental Hospital of …………………………………………………………………. of …………………………….. as a person of unsound mind.

    2. I am over 21 years of age and I have personally seen the said ………………………………………… ………………………………… within fourteen days immediately prior to the date hereof.

    3. (a)    I am the husband/wife of the said …………………………………………………………………..

or

    (b)    I am related to the said ………………………………………….. in the following manner …………………………………………….

and

the said …………………………………………………………………. is unmarried

or

the husband/wife of the said ………………………………….. is absent, incapacitated, has neglected, is unwilling to present a petition

or

    (c)    I am not related to the said ………………………………………..

    I am connected with the said ……………………………………………. in the following manner:

    The reasons why this petition is not presented by a relative of the said ……………………………. are as follows—

    ………………………………………………………………………………………………

    4. I submit herewith a medical certificate signed by ………………………………………….. who is/is not a relative, partner, or assistant of the said ……………………….. or of the petitioner.

The said …………………………….. is related to ……………………………… the said …………………… ………………………………… or to the petitioner in the following manner:

    5. No previous application has been presented in any Court for a judicial inquiry into the mental capacity of the said …………………………………………………. or

    A previous application was presented on the ………………….. day of ……………………. 19 ….. in the …………………………………………. Court …………………………………….. for a judicial inquiry into the mental capacity of the said …………………………………………….. A certified copy of the order made thereon is attached hereto.

    The Petitioner therefore prays that the Court will be pleased to make a reception order as prayed.

    I certify that the above statements are true.

    Dated …………………………………………………

Signature ……………………………………

Petitioner

STATEMENT OF PARTICULARS

(If any of the particulars in this statement are not known, the fact to be so stated.)

The following is a statement of particulars relating to the said person:

Name of patient at length…………………………………………………………………………………………

Sex and age…………………………………………………………………………………………………………

Married, single or widowed ………………………………………………………………………………………

Occupation ………………………………………………………………………………………………………….

Tribe and religious belief, as far as known ……………………………………………………………………

Residence …………………………………………………………………………………………………………..

Names of relatives …………………………………………………………………………………………………

When first showed signs of unsoundness of mind…………………………………………………………..

Age (if known) on first attack …………………………………………………………………………………….

Whether previously under care and treatment ………………………………………………………………..

Supposed cause …………………………………………………………………………………………………….

Whether the patient is subject to epilepsy …………………………………………………………………….

Whether suicidal …………………………………………………………………………………………………….

Whether he is known to be suffering from phthisis or any form of tubercular disease…………………. ……………………………………………………….

Whether dangerous to others, and in what way ……………………………………………………………..

Whether he is capable of looking after himself ………………………………………………………………

With whom he has been living …………………………………………………………………………………..

Whether the patient is addicted to the use of any drug or intoxicant ……………………………………

Whether any near relative (stating the relationship) has been afflicted with insanity …………………. …………………………………………………………..

    I certify that the above statements are true.

Date ………………………………..

…………………………………………………………..

Signature of person making the Statement

    In the matter of ……………………………

    In the District of …………………………..

    I, …………………………………. do hereby certify as follows—

    1. On the ………………… day of ………………19 …,

    at ……………………………….. in the District of ………………………

    I personally examined the said ………………………………..

    and I am of opinion that the said …………………………….

    is of unsound mind and a proper person to be taken charge of and detained under care.

    2. I formed this conclusion on the following grounds—

    (a)    Facts indicating insanity observed by myself:—

        (Here state observations)

    (b)    Other facts, if any, indicating insanity communicated to me by others.

        (Here state information and from whom)—

    Here state whether the person giving the certificate is a registered or a licensed medical practitioner.

    Signed ……………………………….. Qualifications ……………………………..

    In the ……………………………………. Subordinate Court

    of ……………………………..

    Whereas …………………………………………………………………………………. has been brought before this Court (on the petition of …………………………………………………….. ) under section …………………………………..

    of this Act.

    And whereas ……………………………………………………………………. *State whether a registered or a licensed medical practitioner.

    has examined the said ………………………………………………………………. and furnished me with a certificate as to…