Approved Form 14a - Authority To Escort For Assessment printable pdf download

CHIEF CIVIL PSYCHIATRIST APPROVED FORM 14A

THCI: (Patient Id):

AUTHORITY TO ESCORT

Family Name: __________ Given Name:___________

(ENSURING PATIENT

DOB: _____/_____/_____ Gender: M ☐ F☐ TG/IT☐

PRESENTS FOR ASSESSMENT)

Address:

_________________________________________

Mental Health Act 2013

______________

Phone: ____________ Mob:

Section 31 and Schedule 2

AFFIX STICKER HERE

PART A: AUTHORITY TO ESCORT - PATIENT SUBJECT TO

ASSESSMENT ORDER

MEDICAL PRACTITIONER TO COMPLETE

Patient’s name: _____________________________________________________________________________

Medical practitioner’s name: __________________________________________________________________

An Assessment Order is

I hereby request that the patient named above be taken under escort to ensure that he or she

authority for any Mental

presents for assessment under the Assessment Order to which he or she is subject (tick

Health Officer (MHO) or

Police Officer to take the

appropriate box):

patient under escort to ensure

that he or she presents for

☐ To the place of assessment recommended in the Assessment Order

assessment under the Order if

this is requested by either the

OR ☐ To the following approved hospital:

medical practitioner who

made the Order or by any

☐NWRH (Burnie) ☐LGH ☐RHH ☐Roy Fagan Centre ☐ Millbrook Rise Centre

other medical practitioner.

An Assessment Order is also

OR ☐ To the following place of assessment: ______________________________________

authority for the patient to be

admitted to an approved

I hereby also request that the patient named above be admitted to and detained in:

facility and, if necessary,

detained in an approved

☐ The approved hospital named in the patient’s Assessment Order

facility for and in connection

with the assessment, if this is

☐ The approved hospital referred to above

authorised by either the

medical practitioner who

made the Order (and is

☐ Assessment Order attached

apparent from the terms of

Patient’s description (gender, hair and eye colour, approximate height, attire when last seen):

the Order) or by any other

medical practitioner using this

form.

________________________________________________________________________

However, a medical

practitioner may only seek to

________________________________________________________________________

have a patient who is a child

detained in an approved

________________________________________________________________________

hospital if the practitioner is

satisfied that the hospital has

facilities and staff for the

Last known whereabouts: _____________________________________________________

treatment and care of the

patient, and is, in the

________________________________________________________________________

circumstances, the most

appropriate place to

accommodate the patient.

Any other relevant information: ________________________________________________

The custody and escort

provisions set out in Schedule

________________________________________________________________________

2 apply to the patient’s escort

to ensure that he or she

Date and time of request: Date: ______/______/______

Time: _______:________ (24 hr)

presents for assessment for

so long as the patient is

subject to the Assessment

Medical practitioner’s signature: ____________________________________________

Order.

COPY TO: ☐ Escort (MHO or Police Officer) ☐ CCP ☐ LOC

CONTACT DETAILS: CCP: Ph: (03) 6166 0781 Fax No: (03) 6230 7739 Email:

chief.psychiatrist@dhhs.tas.gov.au

Police: Ph: (03) 6230 2434

Fax No: (03) 6230 2414

Email:

rds@police.tas.gov.au

Version 3: 15 December 2014

Page 1 of 2

Approved Form 14a - Authority To Escort For Assessment

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