Form 10c - Office Of The Chief Psychiatrist Of Western Australia - Record Of Informing Medical Practitioner And Treating Psychiatrist Of Bodily Restraint

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CHIEF PSYCHIATRIST
FAMILY NAME
UMRN
OF
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
BIRTHDATE
GENDER
WA MENTAL HEALTH
ACT 2014
ADDRESS
SECTIONS: 230, 231, 233
FORM 10C – RECORD OF INFORMING MEDICAL PRACTITIONER AND TREATING
PSYCHIATRIST OF BODILY RESTRAINT
Informing medical practitioner of bodily restraint (if applicable – see overleaf):
Name of medical practitioner: __________________________________________________
Qualifications of medical practitioner: ____________________________________________
Date and time medical practitioner informed:
Date:
DD/MM/YY
Time:
HH:MM
Informing treating psychiatrist of bodily restraint (if applicable – see overleaf):
Name of treating psychiatrist: __________________________________________________
Qualifications of treating psychiatrist: ____________________________________________
Date and time treating psychiatrist informed:
Date:
DD/MM/YY
Time:
HH:MM
Name of person completing this form:_____________________________________________
Signature: ____________________________________________________________________
March 2016

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