Form 6a - Inpatient Treatment Order In Authorised Hospital - Chief Psychiatrist Of Western Australia
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CHIEF PSYCHIATRIST
FAMILY NAME
UMRN
OF
GIVEN NAMES
CMHI
WESTERN AUSTRALIA
BIRTHDATE
GENDER
WA MENTAL HEALTH
ACT 2014
ADDRESS
SECTIONS: 55, 56, 72, 89, 90, 120, 123, 131
FORM 6A – INPATIENT TREATMENT ORDER IN AUTHORISED HOSPITAL
Authorised hospital where the
person is to be an involuntary inpatient: ___________________________________________
Reasons for making the inpatient treatment order:
All requirements must be met. (Tick the boxes to confirm.)
the person has a mental illness requiring treatment;
because of the mental illness there is a significant risk to the health or safety of the
person or to the safety of another person, or a significant risk of serious harm to the
person or to another person;
the person does not demonstrate the capacity to make a decision about provision of
treatment to himself or herself;
treatment in the community cannot reasonably be provided to the person; and
there is no alternative that would be less restrictive to the person’s freedom of choice and
movement.
Any additional evidencing comments (optional):
Name of the psychiatrist making the order: _______________________________________
Qualifications of the psychiatrist making the order: ________________________________
Signature of the psychiatrist making the order: ____________________________________
Date and time order made:
Date:
DD/MM/YY
Time
HH:MM
:
Date and time inpatient treatment order will expire:
Date:
DD/MM/YY
Time
HH:MM
:
(Up to 21 days for adults, and 14 days for children, from the day on which the order is made)
REVOCATION OF INPATIENT TREATMENT ORDER (If required)
Reasons for revoking order:
I am satisfied that the involuntary inpatient is no longer in need of the inpatient treatment
order.
Any comments (optional):
Name of the revoking psychiatrist: _______________________________________________
Qualifications: ________________________
Signature: ____________________________
Date and time revocation order made:
Date:
DD/MM/YY
Time
HH:MM
:
March 2016
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