Form 5 - Mental Health Commission

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Revised December 2011
RECOMMENDATION
FORM 5
(BY A REGISTERED MEDICAL PRACTITIONER)
MENTAL HEALTH
FOR INVOLUNTARY ADMISSION OF AN ADULT
ACT 2001
(as amended)
(TO AN APPROVED CENTRE)
SECTION 10
PAGE 1 OF 2
BLOCK CAPITALS
(Before completing this form please read the notes overleaf)
In accordance with Part 2 of the Mental Health Act 2001 as amended)
I,
(Full Name of Registered Medical Practitioner)
1
. Professional Address
of Registered
Medical Practitioner
2
. Medical Practitioner
I am the person’s general medical practitioner
Yes
No
Registration Number
recommend that
3
. Full Name and Home
Address of PERSON
the subject of the
recommendation
4
. Date of Birth OR Age
/
/
(if Date of Birth not known)
Age:
Gender
M
F
be admitted to
5
. Name and address of
Approved Centre
I last examined the person on
6
. Date:
Time:
:
/
/
(24 hour clock e.g. 2.41p.m. is written as 14.41)
Which was within 24 hours of receipt of the application for involuntary admission which was made on
by;
/
/
(Name of Applicant)
7.
In my opinion this person is suffering from a mental disorder where-
(a) because of the illness, disability or dementia, there is a serious likelihood of the person concerned causing immediate
and serious harm to himself or herself or to other persons,
OR
(b) (i) because of the severity of the illness, disability or dementia, the judgement of the person concerned is so impaired
that failure to admit the person to an approved centre would be likely to lead to a serious deterioration in his or her
condition or would prevent the administration of appropriate treatment that could be given only by such admission,
AND
(ii) the reception, detention and treatment of the person concerned in an approved centre would be likely to benefit or
alleviate the condition of that person to a material extent.
OR
(a) (as above) and (b) (as above)
8.
Give clinical description of the person’s mental condition
My opinion above is based on the following grounds
I have informed the above named person of the purpose of the examination;
Yes
No
Where “No” is indicated I
(name) confirm that such
information has been withheld because the provision of such information would be prejudicial to the
person’s mental health or well-being or emotional condition.
I am not a person disqualified for making a recommendation (see Section 10 (3) replicated overleaf)
Signed:
(Registered Medical Practitioner)
Date:
Time:
:
/
/
(24 hour clock e.g. 2.41p.m. is written as 14.41)
For use only in accordance with the Mental Health Act 2001 as amended). Penalties apply for giving false or misleading information.

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