Order Authorizing Reception And Detention In An Authorised Hospital For Further Examination
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CHIEF PSYCHIATRIST
FAMILY NAME
Please use ID label or block print
UMRN
CHIEF PSYCHIATRIST
OF
FAMILY NAME
UMRN
OF
WESTERN AUSTRALIA
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
GIVEN NAMES
CMHI
BIRTHDATE
GENDER
WA MENTAL HEALTH
WA MENTAL HEALTH
ACT 2014
BIRTHDATE
GENDER
ACT 2014
ADDRESS
ADDRESS
SECTION: 61
SECTION: 61
FORM 3D – ORDER AUTHORISING RECEPTION AND DETENTION IN AN
FORM 3D – ORDER AUTHORISING RECEPTION AND DETENTION IN AN
AUTHORISED HOSPITAL FOR FURTHER EXAMINATION
AUTHORISED HOSPITAL FOR FURTHER EXAMINATION
N E
This order can only be made following examination by a psychiatrist in a place other than an
authorised hospital.
Place where person examined: ___________________________________________________
(Must not be an authorised hospital)
Place where person is to be
received for further examination: _________________________________________________
(Must be an authorised hospital)
Reasons for making this order:
I have examined the person and am of the opinion that the person requires an examination by a
psychiatrist at an authorised hospital.
Any comments (optional):
Name of psychiatrist making this order:
_________________________________________
Qualifications: ________________________________________________________________
Signature: ___________________________________________________________________
Date and time order made:
Date:
DD/MM/YY
Time
HH:MM
:
Receival at authorised hospital:
Date:
DD/MM/YY
Time
HH:MM
Signature:
:
November 2015
November 2015
Page 1 of 2
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