MENTAL DISORDERS: SUBSIDIARY LEGISLATION
INDEX TO SUBSIDIARY LEGISLATION
Mental Disorders (Forms) Regulations
MENTAL DISORDERS (FORMS) REGULATIONS
(under section 51)
(19th March, 1971)
ARRANGEMENT OF REGULATIONS
REGULATION
1. Citation
2. Forms
Schedule
S.I. 33, 1971
These Regulations may be cited as the Mental Disorders (Forms) Regulations.
The forms set out in the Schedule and specified in the table of forms set out herein are prescribed for the purposes of the sections of the Act which are set in relation to such forms in such table.
TABLE OF FORMS
|
Form |
Nature of Form |
Relevant sections |
|
1 |
Application for Reception Order |
5 |
|
2 |
Medical Practitioner’s Certificate as to Mental State of Patient |
6, 16, 17 or 29(1) |
|
3 |
Medical Practitioner’s Certificate as to desirability of Further Detention of Patient |
15 |
|
4 |
Reception Order |
9 |
|
5 |
Application by Police Officer for Reception Order |
12 |
|
6 |
Urgent Application |
17 |
|
7 |
Application for Reception Order |
20 |
|
8 |
Order for Further Detention |
21 |
|
9 |
Master’s Order for Further Detention |
27(1)(a) |
|
10 |
Direction for Patient’s Removal to an Institution |
28 |
|
11 |
Superintendent’s Annual Report on Patient |
32(1) |
|
12 |
Notification of Death or Escape of Detained Patient |
32(3) |
|
13 |
Medical Certificate that Patient no longer mentally disordered or defective |
34 |
|
14 |
Application for Own Admission as Voluntary Patient |
36(1) |
|
15 |
Application for admission of person under 16 years as voluntary patient |
36(2) |
|
16 |
Medical Recommendation |
36 |
|
17 |
Warrant for Removal of Patient from Botswana |
52 |
SCHEDULE
Form 1
APPLICATION FOR RECEPTION ORDER
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 5) |
|
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To: The District Commissioner, |
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|
………………………………………………………… |
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(a) Particulars of Applicant |
Full names ……………………………………………………………………….. |
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Age ………………………….. Sex …………………………………………….. |
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Occupation ………………………………………………………………………. |
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Address …………………………………………………………………………… |
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(b) Particulars of person for whom reception order is sought |
Full names ……………………………………………………………………….. |
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Age ………………………….. Sex …………………………………………….. |
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Occupation ………………………………………………………………………. |
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Nationality ……………………………………………………………………….. |
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Address …………………………………………………………………………… |
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(c) I declare that I am the person described in paragraph (a) above and I hereby make application for a reception order under the Act, for the person described in paragraph (b)(hereinafter called the patient). |
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(d) I believe the patient is mentally disordered or defective. |
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(e) My reasons for so believing are as follows- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(f) The patient is my ……………………………………………………………………………………. |
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…………………………………………………………………………………………………………… |
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or I am not a near relative of the patient and the reason why the application is made by me instead of by a near relative is |
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…………………………………………………………………………………………………………… |
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(g) I personally saw the patient on the ……… day of ………………………, 20….. (within 14 days immediately preceding the day on which this application is signed). |
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Signed ……………………………………………….. |
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Date …………………………………………………. |
Form 2
MEDICAL PRACTITIONER’S CERTIFICATE AS TO MENTAL STATE OF PATIENT
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 6, 16, 17 or 29(1)) |
|
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(a) I, …………………………………………………………………. (give full names) residing at………………………………………………………………………………………………………. being a registered medical practitioner, hereby certify that at ……………… (state hour) on the …….. day of ………………………, 20 ……, at …………………………….. I personally examined ………………………………………………………being a male/female approximately………………………………………………………. years of age whose address is ……………………………………………………………………………………. |
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(b) As a result of the examination I am of the opinion that the patient belongs to Class I/Class II/Class III of mentally disordered or defective persons specified in section 3 of the Act. |
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(c) The following facts indicative of mental disorder or defect were observed by me during the abovementioned examination- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(d) The following facts indicative of mental disorder or defect have been observed by me on previous occasions (give approximate dates)- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(e) The following facts indicative of mental disorder or defect have been communicated to me (set out facts communicated by other persons with names and addresses of those persons)- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(f) In my opinion the factors which have caused the mental disorder or defect are ………. |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(g) In my opinion the patient is not suicidal/homicidal/in any way dangerous to himself or others (strike out what is inapplicable). |
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(h) The following treatment has been received by the patient in respect of his/her mental condition- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(i) The bodily health and condition of the patient is as follows- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(j) Is any communicable disease present? Yes/No. |
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If so, what? ……………………………………………………………………………………………. |
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…………………………………………………………………………………………………………… |
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(k) Is any recent injury present? Yes/No. |
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If so, what? ……………………………………………………………………………………………. |
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…………………………………………………………………………………………………………… |
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(l) In my opinion the patient does/does not require skilled medical attention. |
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(m) (under section 17). In my opinion this is/is not a case of urgency in which the patient should be immediately removed to an institution/hospital/prison/cell. |
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(n) (under section 29(1)). In my opinion it is/is not desirable that the patient shall remain under private care for the following reasons- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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I certify that I am not prohibited by the Act from signing this certificate and that I am a duly registered medical practitioner. |
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|
…………………………………………………………. |
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Date ………………………………………………….. |
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Place ………………………………………………… |
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Form 3
MEDICAL PRACTITIONER’S CERTIFICATE AS TO DESIRABILITY OF FURTHER DETENTION
OF PATIENT
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 15) |
|
|
(a) I, …………………………………………………………………. (give full names) residing at ……………………………………………. being a registered medical practitioner, and being the practitioner on whose certificate a reception order endorsed under section 10 of the Act, was granted on the ……….. day ………………………….., 20 …………… by the District Commissioner, ………………………………., in respect of the patient ………………………………………………………………… being a male/female approximately ……………………………………….. years of age whose address is…….., hereby certify that at ………………………….. (state hour) on the ………………………… day of ………………………………., 20…………………… at …………………………………, I again personally examined the said patient. |
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(b) As a result of the examination I am of the opinion that the patient belongs to Class I/Class II/Class III of mentally disordered or defective persons specified in section 3 of the Act. |
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(c) The following facts indicative of mental disorder or defect were observed by me during the above-mentioned examination- |
|
|
…………………………………………………………………………………………………………… |
|
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…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(d) The following facts indicative of mental disorder or defect have been observed by me on previous occasions (give approximate dates) ……………………………………………… |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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(e) The following facts indicative of mental disorder or defect have been communicated to me (set out facts communicated by other persons with names and addresses of those persons)- |
|
|
…………………………………………………………………………………………………………… |
|
|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(f) In my opinion the factors which have caused the mental disorder or defect are ……….. |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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(g) In my opinion the patient is/is not suicidal/homicidal/in any way dangerous to himself or others (strike out what is inapplicable). |
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(h) The following treatment has been received by the patient in respect of his/her mental condition- |
|
|
…………………………………………………………………………………………………………… |
|
|
…………………………………………………………………………………………………………… |
|
|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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(i) The bodily health and condition of the patient is as follows- |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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(j) Is any communicable disease present? Yes/No. |
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If so, what? ……………………………………………………………………………………………. |
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…………………………………………………………………………………………………………… |
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(k) Is any recent injury present? Yes/No. |
|
|
If so, what? ……………………………………………………………………………………………. |
|
|
…………………………………………………………………………………………………………… |
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|
…………………………………………………………………………………………………………… |
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(l) In my opinion the patient does/does not require skilled medical attention. |
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I certify that the further detention of the patient for a period of at least …………………………… |
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days is desirable for the following purposes ……………………………………………………………….. |
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|
………………………………………………………………………………………………………………………… |
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|
………………………………………………………………………………………………………………………… |
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I certify that I am not prohibited by the Act from signing this certificate and that I am a duly registered Medical Practitioner. |
|
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|
…………………………………………………………. |
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Date ………………………………………………….. |
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Place ………………………………………………… |
|
Form 4
RECEPTION ORDER
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 9) |
|
|
To the Officer in Charge, |
|
|
………………………………………………………………………………………………………………………… |
|
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…………………………………………….. (institution or place of detention). |
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I, ……………………………………………………………………., District Commissioner of …………….. …………………………………………………………………………………………………, being satisfied- |
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(1) that the undermentioned patient is mentally disordered or defective; and |
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(2) that he/she- |
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* (a) is not under proper care, treatment or control; |
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* (b) is cruelly treated or neglected by a relative or other person having the care or charge of him/her; |
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* (c) is of suicidal or homicidal tendency or is in any way dangerous to himself/herself or others; or |
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* (d) has committed or attempted to commit a crime or offence or has acted in a manner offensive to public decency; or |
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(3) that the person having the care, treatment or control of the patient consents, do hereby authorise the patient to be removed to ……………………………………………… and do hereby order you to receive and to detain him/her under the provisions of the Act in the institution/place of detention under your charge for |
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(a period not exceeding 30 days). |
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Full names of patient ……………………………………………………………………………………………. |
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Sex …………………………… Age …………………………… Nationality …………………………………. |
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Address ……………………………………………………………………………………………………………. |
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I have determined that the patient belongs to Class I/Class II/Class III specified in section 3 of the Act. |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
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ENDORSEMENT (IF ANY) UNDER SECTION 10 OT THE ACT |
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This order is granted for the temporary treatment of the patient only. |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
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Endorsement (if any) under section 15 of the Act of order endorsed under section 10 of the Act- |
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I hereby extend the period of detention authorised above for a period of …………………………. (not exceeding 30 days). |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
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Endorsement (if any) under section 16 of the Act of order not endorsed under section 10 of the Act- |
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I hereby extend the period of detention authorised above for a further period of ………………… (not exceeding 60 days). |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
>*Delete whichever is inapplicable.>
Form 5
APPLICATION BY POLICE OFFICER FOR RECEPTION ORDER
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 12) |
|
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To: The District Commissioner, |
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|
…………………………………………………………. |
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(a) Particulars of Applicant |
Full name …………………………………………………………………………. |
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Rank ………………………………………………………………………………. |
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(b) Particulars of patient for whom reception order is required |
Full names ……………………………………………………………………….. |
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Age …………………………….. Sex ………………………………………….. |
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Occupation ……………………. Nationality …………………………………. |
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Address …………………………………………………………………………… |
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(c) I declare that I am the person described in paragraph (a) and that I am an officer of the Botswana Police Force and hereby make application for a reception order under the Act, for the person described in paragraph (b) (hereinafter called the patient). |
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(d) I believe that the patient is mentally disordered or defective. |
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(e) My reasons for so believing are as follows- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(f) I further believe that the patient- |
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FIND*”/>is neglected or cruelly treated by a person having the care or charge of him/her; |
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FIND*”/>acts in a manner offensive to public decency; |
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FIND*”/>is not under safe and proper supervision, care or control; |
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FIND*”/>is dangerous to himself/herself or others. |
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(g) My reasons for so believing are as follows: |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………. |
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Date ………………………………………………….. |
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Place …………………………………………………. |
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>*Delete whichever is inapplicable.>
Form 6
URGENT APPLICATION
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 17) |
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To: The Officer in Charge, |
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|
……………………………………….. (institution/hospital prison/cell) |
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(a) Particulars of applicant |
Full names ………………………………… |
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Address …………………………………….. |
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Age …………………………….. Sex …… Occupation ……………………………….. |
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Precise relationship to patient …………………………………………….. |
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If not near relative, state reasons why application is being made by applicant instead of by near relative- |
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……………………………………………………………………………………… |
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……………………………………………………………………………………… |
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(b) Particulars of person for whom urgent reception is sought |
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Full names …………………………………………………………………….. |
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Address …………………………………………………………………………. |
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Age …………………….. Sex …………………….. Occupation ………………………………………….. |
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(c) Grounds on which applicant believes patient is mentally disordered or defective- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(d) The matter is one of urgency for the following reasons- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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I, the applicant whose particulars are stated in paragraph (a), request you to receive and detain the patient described in paragraph (b) in your institution/hospital/prison/cell. |
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I have personally seen the said patient within the last 48 hours. |
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I attach a medical certificate from Dr. ……………………………………………….. I am of full age. |
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…………………………………………………………. |
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Date …………………. |
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Place ………………………………………………… |
Form 7
APPLICATION FOR RECEPTION ORDER
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
|
(section 20) |
|
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To: The District Commissioner, |
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|
………………………………………………………… |
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(a) Particulars of applicant- |
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Full names ……………………………………………………………………………………………. |
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Address ……………………………………………………………………………………………….. |
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Official position or rank …………………………………………………………………………….. |
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(b) Particulars of patient for whom reception order is sought- |
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Full names ………………………………………………………………………………………….. |
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Sex ……………………. Age ……………………. Occupation …………………………………. |
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Nationality …………………………………………. Address …………………………………….. |
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1. On the ……………… day of ……………. 20 …………….. the above-named patient was received into …………………………………… (specify institution/ hospital/prison/cell): * on an urgent application made by me under section 17 of the Act, accompanied by a medical certificate, of which application and certificate I attach copies hereto. |
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FIND*”/>after being apprehended and conveyed by me to the said……………………………….. ……………………………………………………….. (specify institution/hospital/prison/cell) under section 19 of the Act, in the belief that the said patient was mentally disordered or defective and dangerous to himself or others and that it was necessary for the public safety/for the welfare of the patient that he should be placed under immediate care and control. I still hold this belief, which is based on the following facts- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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2. (Except where copy of a medical certificate accompanying an application under section 17 of the Act is stated in paragraph 1 to be attached) I have called in the advice of Dr. ………………………………………………… a registered medical practitioner of ……………………………………. and for the purposes of section 9(4) of the Act I attach a copy of a certificate made by him after examining the said patient. |
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3. In terms of section 20(1) of the Act, I make application for a reception order to be issued in respect of the said patient: |
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…………………………………………………………………………………………………………… |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
>*Delete whichever is inapplicable.>
Form 8
ORDER FOR FURTHER DETENTION
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
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(section 21) |
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To: The Officer in Charge, |
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…………………………………………. (institution/hospital/prison/cell) |
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I, …………………………………………………………, District Commissioner of …………………….. having considered an application under section 20 of the Act relating to the patient |
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………………………………………………………………………………………………………………………… |
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Sex ……………………….. Age ……………………….. Occupation ……………………………………….. |
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Nationality ……………………………………………. Address ……………………………………………… |
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do hereby order that the said patient be further detained for a period/periods of ……………………………………………… (not exceeding 14 days) for the purpose of deciding whether or not the patient is mentally disordered or defective. |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
Form 9
MASTER’S ORDER FOR FURTHER DETENTION
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
|
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(section 27(1)(a)) |
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To: The Officer in Charge, |
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………………………………………………. (institution or place of detention). |
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I, ………………………………………………………, Master of the High Court of Botswana, having considered the reception order made on the …………………… day of ………………………………… 20 ……………………….. by the District Commissioner, …………………………………………………. in respect of the patient (full names) ………………………………………………………………………… |
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(sex) ……………………………. (age) …………………. (nationality) ……………………………………. |
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(address) …………………………………………………………………………………………………………. and additional documents, and being satisfied that an order for the further detention of the said patient should be made, do hereby, in terms of section 27(1)(a) of the Act, order you to detain him/her under the provisions of the said Act in the institution/place of detention under your charge for …………………………………………………………………………………………………………. |
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(state a definite or indefinite period). |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
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Copy to: Director of Medical Services |
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Form 10
DIRECTION FOR PATIENT’S REMOVAL TO AN INSTITUTION
|
REPUBLIC OF BOTSWANA |
|
|
MENTAL DISORDERS ACT |
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(section 28) |
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To: The Officer in Charge, |
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……………………………………….. (institution or place of detention) |
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To: The Officer in Charge, |
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………………………………………………. (Institution) |
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WHEREAS on the ……………… day of ………………………………. 20 ……………………. the District |
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Commissioner ………………………………………………………………………………………… issued a reception order in respect of the patient (full names) …………………………………………………….. |
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………………………………………………………………………………………………………………………… |
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(sex) ……………………………. (age) …………………. (nationality) ……………………………………… |
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(address) ………………………………………………………………………………………………………….. |
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FIND*”/>authorising the said patient to be detained in …………………………………………………………….. (institution or place of detention); |
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FIND*”/>AND WHEREAS on the ………………… day of ……………………………………. 20 ……………… the Master of the High Court made a further detention order in respect of the said patient; |
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I, ……………………………………………………………………. Director of Medical Services, do now in terms of section 28 of the Act, authorise the officer in charge of …………………………………… |
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………………………………………………………………………………………………………………………… |
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(institution or place of detention) to cause the said patient to be removed to …………………………………………….. (institution), there to be detained until legally discharged or transferred to some other place. |
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Dated at …………………………. this ……………………… day of ……………………. 20 ……………… |
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…………………………………………………………. |
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Copy to: The Master of the High Court. |
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>*Delete if inapplicable.>
Form 11
SUPERINTENDENT’S ANNUAL REPORT ON PATIENT
|
REPUBLIC OF BOTSWANA |
|
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MENTAL DISORDERS ACT |
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|
(section 32(1)) |
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To: The Director of Medical Services. |
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Copy to: The Master of the High Court. |
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Full names of patient ……………………………………………………………………………………………. |
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Sex …………………………… Age ………………… Nationality ……………………………………………. |
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Hospital number ……………………………. Date of admission …………………………………………… |
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Date of Master’s Order for further detention ………………………………………………………………… |
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(a) Present state of physical condition- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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Height ………………………… Weight …………………………………………………………… |
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Note gain or loss during the year ………………………………………………………………… |
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(b) Disease or injuries suffered since last report (if any)- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(c) Diagnosis and comments on mental condition- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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(d) Recommendations and general remarks or observations (if any)- |
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…………………………………………………………………………………………………………… |
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…………………………………………………………………………………………………………… |
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Signed ……………………………………………….. |
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………………………………………………………… |
Form 12
NOTIFICATION OF DEATH OR ESCAPE OF DETAINED PATIENT
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 32(3)) |
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I have to report that ………………………………………………………………………….. (full names) |
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(sex) ………………….. (age) ………………………………. (nationality) ………………………………….. |
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Hospital number ……………………………………….. who has been detained at ……………………… |
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(institution or place of detention) since the ……………….. day of ………………… 20 ……………… died/escaped at ……………… (hour) on the ………… day of ………………. 20 ………………………. |
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Signed ……………………………………………. |
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……………………………………………………. |
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Date ………………………………………………….. |
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In case of death- |
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To: |
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(1) The District Commissioner …………………………………………………………………………….. |
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(2) The District Registrar of Births and Deaths ………………………………………………………… |
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(3) The Director of Medical Services ……………………………………………………………………… |
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(4) The Master of the High Court ………………………………………………………………………….. |
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(5)(Where patient detained in prison) The Commissioner of Prisons |
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In case of escape- |
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To: |
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(1) The District Commissioner …………………………………………………………………………….. |
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(2) The Officer in Charge ………………………………………………………………… Police Station. |
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(3) The Director of Medical Services ……………………………………………………………………… |
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(4) The Master of the High Court ………………………………………………………………………….. |
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(5)(Where patient detained in prison) The Commissioner of Prisons |
Form 13
MEDICAL CERTIFICATE THAT PATIENT NO LONGER MENTALLY DISORDERED OR
DEFECTIVE
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 34) |
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I, ………………………………………………………………. a registered medical practitioner of …………………………………….. certify that I have on the . ………….day of ………………… 20 ….. examined (full names) ……………….. (sex) ……………………. (age) ……….. (hospital number) …………………………………………….. who has been detained at (institution or place of detention) as a mentally disordered or defective person under the Act. |
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From this examination I find that the said …………………………………………………………………… is no longer mentally disordered or defective. |
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His/her mental state I find to be as follows- |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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I recommend/do not recommend that he/she be released from detention. |
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…………………………………………………………. |
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Date ………………………………………………….. |
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Place ………………………………………………… |
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Form 14
APPLICATION FOR OWN ADMISSION AS VOLUNTARY PATIENT
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 36(1)) |
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To: The Superintendent, |
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……………………………………………….. (institution, hospital, nursing home or authorised place) |
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I, (full names) ……………………………………………………………………………………………………… |
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(sex) …………………. (age) ………………. (occupation) …………………………………… (nationality) |
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…………………………………………………… (address) …………………………………………………….. |
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being over the age of 16 years and desirous of voluntarily submitting myself to treatment for a mental disorder or defect, namely ……………………………………………………………………………. |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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do hereby apply to be received and detained without a reception order as a voluntary patient at |
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……………………………………………………………………………………………………………………….. |
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……………………………………………………………………………………………………………………….. |
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…………………………………………………………. |
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Date ………………………………………………….. |
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Place ………………………………………………… |
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Form 15
APPLICATION FOR ADMISSION OF PERSON UNDER SIXTEEN YEARS AS VOLUNTARY
PATIENT
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 36(2)) |
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To: The Superintendent, |
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………………………………………………… (institution, hospital, nursing home or authorised place) |
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(a) Particulars of applicant |
Full names ……………………………………………………………………….. |
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Sex ………………….. Age ………………………. Occupation ……………. |
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Address …………………………………………………………………………… |
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Relationship to person described in (b)- |
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(b) Particulars of person to whom application relates |
Full names ………………………………………………………………………. |
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Sex …………………. Age ……………………………. Nationality ………… |
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Address …………………………………………………………………………… |
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1. I am the person described in paragraph (a) above and being desirous of submitting the person described in paragraph (b) to treatment for a mental disorder or defect, namely …………………… |
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………………………………………………………………………………………………………………………… |
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(institution, hospital, nursing home or authorised place). |
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2. A medical recommendation signed by a medical practitioner is attached. |
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……………………………………………………….. |
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Date …………………………………………. |
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Place ………………………………………… |
Form 16
MEDICAL RECOMMENDATION
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 36) |
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I, ……………………………………………………………………., a registered Medical Practitioner of |
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……………………………………………………………………………, certify that I examined (full names) |
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……………………………………………………….. (sex) …………………….. (age) ………………………. |
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(address) ………………………………………………………………………………………………….. on the |
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……………………………………………….. day of ………………………………………. 20 ………………. |
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From this examination I find his/her mental state to be as follows ……………………………………. |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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………………………………………………………………………………………………………………………… |
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I am of the opinion that he/she is likely to benefit by being received and treated for mental illness under section 36 of the Act, and I recommend that he/she be so received and treated. My qualifications are |
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………………………………………………………………………………………………………………………… |
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Signed ……………………………………………….. |
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Date ………………………………………………….. |
Medical Practitioner |
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Place ………………………………………………… |
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Form 17
WARRANT FOR REMOVAL OF PATIENT FROM BOTSWANA
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REPUBLIC OF BOTSWANA |
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MENTAL DISORDERS ACT |
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(section 52) |
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Person to be removed under warrant |
Full names ……………………………………………………………………………….. |
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Sex ……………………. Age ……………………. Occupation …………………….. |
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Nationality ………………………………………………………………………………… |
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State where residing, cared for or detained- |
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………………………………………………………………………………………………. |
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I, ……………………………………………………………., Minister of ……………………………………….. |
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being satisfied- |
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(i) that the person described above has been declared by the High Court to be mentally disordered or defective; |
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(ii) that he/she should be removed from Botswana to: |
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…………………………………………………………………………………………………………… |
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(iii) that such removal is likely to be for his/her benefit, |
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(iv) that proper arrangements have been made for such removal and for his/her subsequent care and treatment; |
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do hereby authorise such removal and do direct that the said person be delivered to …………….. |
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(name of person) for the purpose of removal from Botswana to ………………………………………… |
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(name other country). |
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Dated at …………………………………. this ………… day of …………………………………. 20……… |
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……………………………………… |