1964_MENTAL_HEALTH_REGULATIONS — Page 3

1989 Ed.]

Mental Health Regulations

[CAP. 136

A 3

SCHEDULE

[Subsidiary]

[reg. 2]

FORM 1

MENTAL HEALTH ORDINANCE

(Chapter 136)

(Section 35A(1))

Application under section 31(1) for removal of a patient to a mental hospital for the purpose of detention and observation

I. [name and address of applicant]

address]

have reason to believe that [name of patient, and, if known, identity card number and

(a) in suffering from mental disorder of a nature or degree which warrants *his/her detention in a mental hospital for *observation/observation followed by medical treatment for at least a limited period;

AND

(b) ought to be so detained (See Note 1)-

(i) in the interests of *his/her own health or safety; and

(ii) with a view to the protection of other persons.

The reasons for my belief are-

I am *the [state relationship].....

the patient/a registered medical practitioner/a public officer in the Social Welfare Department.

of

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

OR

of this application (See Note 2).

I have been unable to locate any relative of the patient in Hong Kong and it is impracticable to delay the making of an order until a relative can be found (See Note 2).

I apply for an order in accordance with the provisions of section 31(1B) of the Mental Health Ordinance authorizing the removal of the patient to a mental hospital for the purpose of detention and observation.

This application is founded on the attached written opinion of a registered medical practitioner in the prescribed form.

I last saw the patient on [date]

(See Note 3).

* Delete as appropriate.

Notes:

Signed

Date

1.

Delete (i) or (ii) unless both apply.

2.

3.

Delete this paragraph if applicant is a relative.

The applicant must have seen the patient within the previous 14 days.