1964_MENTAL_HEALTH_REGULATIONS — Page 14

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CAP. 136]

Mental Health Regulations

[1989 Ed.

[Subsidiary]

FORM 5

MENTAL HEALTH ORDINANCE

(Chapter 136)

(Section 35A(1)).

Application for admission into guardianship under section 33(1)

To: The Director of Social Welfare.

PART I

I, [name and address of applicant] .

., have reason to believe that--

(a) [name of patient, and, if known, identity card number and address]

is suffering from mental disorder of a nature or degree which warrants *his/her reception into guardianship under section 33(1) of the Mental Health Ordinance;

AND

(b) it is necessary that the patient should be so received (See Note 1)-

(i) in the interests of the welfare of the patient; and

(ii) for the protection of other persons.

The reasons for my belief are-

*The patient is aged

OR

[if the patient's age is not known] *I believe that the patient has attained the age of 18 years.

I am *the [state relationship]

practitioner/a public officer in the Social Welfare Department.

of the patient/a registered medical

I have consulted a relative of the patient, namely *his/her [state relationship and name and

address of relative]

about this application (See Note 2).

OR

I have been unable to locate any relative of the patient in Hong Kong (See Note 2).

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