New South Wales Consolidated Acts

MENTAL HEALTH AND COGNITIVE IMPAIRMENT FORENSIC PROVISIONS ACT 2020 - SCHEDULE 1

SCHEDULE 1 – Medical certificate as to examination of inmate

(Section 86(3))

Mental Health and Cognitive Impairment Forensic Provisions Act 2020

I, [name in full--use block letters [#93] (*Medical Practitioner/Psychiatrist) ofdo certify that on [date [#93] at [state place where examination took place [#93], separately from any other medical practitioner, I personally examined [name of inmate in full [#93] *detained at [name of correctional centre or detention centre where inmate is imprisoned or detained if not the place where the examination took place [#93], and I am of the opinion that *he/she is *a mentally ill person/a person who has a condition for which treatment is available in a mental health facility.

I have formed this opinion on the following grounds--

(1) Facts indicating *mental illness/condition observed by myself.

(2) Other relevant information (if any) communicated to me by others (state name and address of each informant).

Made and signed this [date [#93]

[Signature [#93]

*Delete whichever does not apply.