New South Wales Consolidated Acts New South Wales Consolidated ActsPart 1
I, [name in full--use block letters [#93] (Medical Practitioner/accredited person) ofcertify that on [date [#93] immediately before or shortly before completing this certificate, at [state place where examination/observation took place [#93] I personally/by audio visual link examined/personally/by audio visual link observed [name of person in full [#93] for a period of [state length of examination/observation [#93].
I certify the following matters--
1. I am of the opinion that the person examined/observed by me is [strike out alternative that is not applicable [#93]--(a) a mentally ill person suffering from a mental illness and that owing to that illness there are reasonable grounds for believing that care, treatment or control of the person is necessary for the person's own protection from serious harm or for the protection of others from serious harm,(b) a mentally disordered person whose behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary for the person's own protection from serious physical harm or for the protection of others from serious physical harm.
2. I have satisfied myself, by such inquiry as is reasonable having regard to the circumstances of the case, that the person's involuntary admission to and detention in a mental health facility are necessary and that no other care of a less restrictive kind is appropriate and reasonably available to the person.
3. Incidents and/or abnormalities of behaviour and conduct (a) observed by myself and (b) communicated to me by others (state name, relationship and address of each informant) are--(a)
(b)
4. The general medical and/or surgical condition of the person is as follows--
5. The following medication (if any) has been administered for purposes of psychiatric therapy or sedation--
6. I am not a near relative or a designated carer or the principal care provider of the person.
7. I have/do not have a pecuniary interest, directly or indirectly, in a private mental health facility. I have/do not have a near relative/partner/assistant who has such an interest. Particulars of the interest are as follows--
Made and signed this [date [#93]
[Signature [#93]
Part 2
The following persons may transport a person to a mental health facility: a member of staff of the NSW Health Service, an ambulance officer, a police officer.
If the assistance of a police officer is required, this Part of the Form must be completed.
YOU SHOULD NOT REQUEST THIS ASSISTANCE UNLESS THERE ARE SERIOUS CONCERNS RELATING TO THE SAFETY OF THE PERSON OR OTHER PERSONS IF THE PERSON IS TAKEN TO A MENTAL HEALTH FACILITY WITHOUT THE ASSISTANCE OF A POLICE OFFICER
I have assessed the risk and I am of the opinion, in relation to [name of person in full [#93] that there are serious concerns relating to the safety of the person or other persons if the person is taken to a mental health facility without the assistance of a police officer. The reason for me being of this opinion is [include any information known about the patient relevant to the risk [#93].
Made and signed this [date [#93]
[Signature [#93]
Notes:1 Sections 13- 16 of the Mental Health Act 2007 state--13 Criteria for involuntary admission etc as mentally ill person or mentally disordered person A person is a mentally ill person or a mentally disordered person for the purpose of--(a) the involuntary admission of the person to a mental health facility or the detention of the person in a facility under this Act, or(b) determining whether the person should be subject to a community treatment order or be detained or continue to be detained involuntarily in a mental health facility,if, and only if, the person satisfies the relevant criteria set out in this Part.14 Mentally ill persons(1) A person is a mentally ill person if the person is suffering from mental illness and, owing to that illness, there are reasonable grounds for believing that care, treatment or control of the person is necessary--(a) for the person's own protection from serious harm, or(b) for the protection of others from serious harm.(2) In considering whether a person is a mentally ill person, the continuing condition of the person, including any likely deterioration in the person's condition and the likely effects of any such deterioration, are to be taken into account.15 Mentally disordered persons A person (whether or not the person is suffering from mental illness) is a mentally disordered person if the person's behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary--(a) for the person's own protection from serious physical harm, or(b) for the protection of others from serious physical harm.16 Certain words or conduct may not indicate mental illness or disorder(1) A person is not a mentally ill person or a mentally disordered person merely because of any one or more of the following--(a) the person expresses or refuses or fails to express or has expressed or refused or failed to express a particular political opinion or belief,(b) the person expresses or refuses or fails to express or has expressed or refused or failed to express a particular religious opinion or belief,(c) the person expresses or refuses or fails to express or has expressed or refused or failed to express a particular philosophy,(d) the person expresses or refuses or fails to express or has expressed or refused or failed to express a particular sexual preference or sexual orientation,(e) the person engages in or refuses or fails to engage in, or has engaged in or refused or failed to engage in, a particular political activity,(f) the person engages in or refuses or fails to engage in, or has engaged in or refused or failed to engage in, a particular religious activity,(g) the person engages in or has engaged in a particular sexual activity or sexual promiscuity,(h) the person engages in or has engaged in immoral conduct,(i) the person engages in or has engaged in illegal conduct,(j) the person has an intellectual disability or developmental disability,(k) the person takes or has taken alcohol or any other drug,(l) the person engages in or has engaged in anti-social behaviour,(m) the person has a particular economic or social status or is a member of a particular cultural or racial group.(2) Nothing in this Part prevents, in relation to a person who takes or has taken alcohol or any other drug, the serious or permanent physiological, biochemical or psychological effects of drug taking from being regarded as an indication that a person is suffering from mental illness or other condition of disability of mind.2 In addition to matters ascertained as a consequence of personally/by audio visual link examining or observing the person, account may be taken of other matters not so ascertained where those matters--(a) arise from a previous examination of the person, or(b) are communicated by a reasonably credible informant.3 In the Mental Health Act 2007 ,
"mental illness" is defined as follows--
"mental illness" means a condition that seriously impairs, either temporarily or permanently, the mental functioning of a person and is characterised by the presence in the person of any one or more of the following symptoms--(a) delusions,(b) hallucinations,(c) serious disorder of thought form,(d) a severe disturbance of mood,(e) sustained or repeated irrational behaviour indicating the presence of any one or more of the symptoms referred to in paragraphs (a)-(d).4 In the Mental Health Act 2007 ,
"designated carer" and
"principal care provider" are defined as follows--71 Designated carers(1) The
"designated carer" of a person (the
"patient" ) for the purposes of this Act is--(a) the guardian of the patient, or(b) the parent of a patient who is a child (subject to any nomination by a patient referred to in paragraph (c)), or(c) if the patient is over the age of 14 years and is not a person under guardianship, a person nominated by the patient as a designated carer under this Part under a nomination that is in force, or(d) if the patient is not a patient referred to in paragraph (a) or (b) or there is no nomination in force as referred to in paragraph (c)--(i) the spouse of the patient, if any, if the relationship between the patient and the spouse is close and continuing, or(ii) any individual who is primarily responsible for providing support or care to the patient (other than wholly or substantially on a commercial basis), or(iii) a close friend or relative of the patient.(2) In this section--
"close friend or relative" of a patient means a friend or relative of the patient who maintains both a close personal relationship with the patient through frequent personal contact and a personal interest in the patient's welfare and who does not provide support to the patient wholly or substantially on a commercial basis.
"relative" of a patient who is an Aboriginal person or a Torres Strait Islander includes a person who is part of the extended family or kin of the patient according to the indigenous kinship system of the patient's culture.72A Principal care providers(1) The
"principal care provider" of a person for the purposes of this Act is the individual who is primarily responsible for providing support or care to the person (other than wholly or substantially on a commercial basis).(2) An authorised medical officer at a mental health facility or a director of community treatment may, for the purposes of complying with a provision of this Act or the regulations, determine who is the principal care provider of a person.(3) The authorised medical officer or the director of community treatment must not determine that a person is the principal care provider of another person if the person is excluded from being given notice or information about the other person under this Act.(4) An authorised medical officer or a director of community treatment is not required to give effect to a requirement relating to a principal care provider of a person under this Act or the regulations if the officer or director reasonably believes that to do so may put the person or the principal care provider at risk of serious harm.(5) A principal care provider of a person may also be a designated carer of the person.5 For admission purposes, this certificate is valid only for a period of 5 days, in the case of a person who is a mentally ill person, or 1 day, in the case of a person who is a mentally disordered person, after the date on which the certificate is given.6 An examination or observation may be carried out by audio visual link by a medical practitioner or accredited person if it is not reasonably practicable for a medical practitioner or accredited person to personally examine or observe a person for the purposes of this form.