MENTAL HEALTHCARE ACT, 2017 BOOKLET NIMHANS BENGALURU

MENTAL HEALTHCARE ACT, 2017 BOOKLET

NIMHANS BENGALURU

TABLE OF CONTENTS

PARTS PART1

PART2

TITLE

CAPACITY GUIDANCE DOCUMENT

PROFORMA FOR CAPACITY ASSESSMENT

REQUEST FOR INDEPENDENT ADMISSION

REQUEST FOR ADMISSION WITH HIGH SUPPORT NEEDS REQUEST FOR CONTINUATION OF ADMISSION WITH HIGH SUPPORT NEEDS

REQUEST FOR ADMISSION OF A MINOR

REQUEST FOR DISCHARGE BY INDEPENDENT PATIENT REQUEST FOR DISCHARGE OF A MINOR

REQUEST TO APPOINT A NR FOR MINOR

PERMISSION FOR ECT FOR MINOR

REQUEST FOR LEAVE OF ABSENCE

APPLICATION FOR PSYCHOSURGERY

FORM FOR MAKING, AMENDING/ REVOKING AND CANCELLING ADVANCE DIRECTIVE

APPLICATION FOR PROVISIONAL REGISTRATION (STATE) PROVISIONAL REGISTRATION CERTIFICATE (STATE) APPLICATION FOR PROVISIONAL REGISTRATION (CENTRAL)

PROVISIONAL REGISTRATION CERTIFICATE (CENTRAL) APPLICATION FOR PERMANENT REGISTRATION INDEPENDENT OPINION OF PSYCHIATRIST/MEDICAL OFFICER

INTIMATION OF ADMISSION TO MHRB (SECTION 87,89) INTIMATION OF CONTINUATION OF ADMISSION TO MHRB (SECTION 90)

REQUEST FOR ADMISSION/TRANSFER UNDER SECTION 103

PHYSICAL RESTRAINT AND MONITORING REPORT BASIC MEDICAL RECORDS (OUTPATIENT)

BASIC MEDICAL RECORDS (INPATIENT)

BASIC PSYCHOLOGICAL ASSESSMENT REPORT BASIC MINIMUM STANDARD GUIDELINES FOR RECORDING OF THERAPY REPORT

REQUEST FOR ASSESSMENT/ADMISSION OF PERSONS WANDERING AT LARGE WITH MENTAL ILLNESS REQUEST FOR APPOINTMENT OF NR FOR WMI REQUEST FOR FILING AN FIR UNDER SECTION 100

PAGE NUMBER 7

25 27

47 49 51

53 55 59

61 63

69 73 75 77 79

85 87

PART3

PART4

PART5

PART6

PART 1

Capacity Assessment Guidance Document As per Section 81 of

Mental Healthcare Act, 2017

An Expert Committee to prepare a guidance document on Capacity Document

As per Section 81 (1) of the Mental Healthcare Act, 2017, the Chairman, Central Mental Health Authority appointed an Expert Committee to prepare a guidance document for medical practitioners and mental health professionals, containing procedures for assessing, when necessary or the capacity of persons to make mental health care or treatment decisions. Following Central Authority members were appointed for drafting the guidance document

Dr. B.N. Gangadhar, Chairman of this committee Dr. Nimesh Desai

Dr. Rajesh Sagar

Dr. Prashant Mishra

Dr. Gorav Gupta

Ms. Rajeshwari lyer Mr. Akileshwar Sahay

Mr. D.R. Sachadeva (invited)

The committee acknowledges the contribution of the following professionals in the development of the Capacity Assessment Guidance Document

Dr. Jagadisha Thirthahalli, Professor of Psychiatry, NIMHANS, Bangalore

Dr. Suresh Bada Math, Professor of Psychiatry, NIMHANS, Bangalore

Dr. Nitin Gupta, Professor of Psychiatry, GMCH, Chandigarh

Dr. Naveen C Kumar, Additional Professor of Psychiatry, NIMHANS, Bangalore

Capacity Assessment as per Mental Healthcare Act, 2017 Overview

Capacity is the ability to make a particular decision, having understood the information relating to the decision at hand and appreciating the consequence of making or not making that decision. Capacity is not static, but dynamic in nature. People may have a condition or illness that affects their ability to make decisions. A lack of capacity may be temporary such as that caused by some illnesses or the influence of drugs or alcohol or mood / affective state. A person’s capacity may vary over time depending on the condition or illness that the person experiences.

A person is presumed to have the capacity to make a decision unless there are good reasons to doubt this presumption. In general, capacity is assessed with respect to a specific decision at a specific time. A person is entitled in law to make unwise or imprudent decisions, provided they have the capacity to make the decision. Supported decision-making involves doing everything possible to maximise the opportunity for a person to make a decision for themselves. As per the MHA, 2017All persons with mental illness shall have capacity to make mental healthcare or treatment decisions but may require varying levels of support from their nominated representative to make decisions. A person’s capacity should be assessed in relation to a particular task or decision. Capacity cannot generally be inferred fromone task or decision to another. The person’s lack of capacity may be temporary, or fluctuating. If possible, an assessment of capacity should be done when the person’s condition has improved. For example, if the person has a delirium, it is better to wait until this has resolved. In such patients with Delirium, Severe Manic Excitement, Stupor, Alcohol and other substance use intoxication, Capacity Assessment may not be feasible, and they can be deemed to have “Obvious” lack of capacity and may be recorded as such. Finally, the capacity assessment is based on combination of relevant history, symptoms, behavior observation, mental status examination and diagnosis. It is a clinical judgement of a clinician.

Guidance document is drafted as per the Section 81 of the MHA, 2017

81. (1) The Central Authority shall appoint an Expert Committee to prepare a guidance document for medical practitioners and mental health professionals, containing procedures for assessing, the capacity of persons to make mental health care or treatment decisions.

(2) Every medical practitioner and mental health professional shall, while assessing capacity of a person to make mental healthcare or treatment decisions, comply with the guidance document referred to in sub-section (1) and follow the procedure specified therein.

This guidance document is only a guidance document and does not replace the legal advice. This document is not a structured or checklist instrument and only a guidance document with provision for semi-structured assessment and documenting the capacity assessment findings. The final decision of capacity is based on holistic assessment of behavioral observation, clinical findings, mental status examination, diagnosis and capacity assessment as per the guidance document. Further it is the prerogative and the duty of the Mental Health Professional/Clinician to record the clinical findings in details and/or elaboration of the same.

Mental Healthcare Act, 2017 articulates following regarding the Capacity to make mental healthcare and treatment decisions.

4. (1) Every person, including a person with mental illness shall be deemed to have capacity to make decisions regarding his mental healthcare or treatment if such person has ability to —

(a) understand the information that is relevant to take a decision on the treatment or admission or personal assistance;

(b) appreciate any reasonably foreseeable consequence of a decision or lack of decision on the treatment or admission or personal assistance;

gesture or any other means.

(2) The information referred to in sub-section (1) shall be given to a person using simple language, which such person understands or in sign language or visual aids or any other means to enable him to understand the information.

(3) Where a person makes a decision regarding his mental healthcare or treatment which is perceived by others as inappropriate or wrong, that by itself, shall not mean that the person does not have the capacity to make mental healthcare or treatment decision, so long as the person has the capacity to make mental healthcare or treatment decision under sub-section (1).

Assessment of capacity to make mental healthcare and treatment decisions is to be carried out on any person (above 18 years of age) during the following situations: –

a) The registration of Advance directives as per Section 11(2)d

b) Before invoking the Advance directive as per Section 5(3)

c) Independent admission as per Section 86(2)c

d) Supported Admission as per Section 89(1)c

e) Every week, when admitted under section 89(8)

f) Supported Admission as per Section 90(12)

g) Every fortnightly, when admitted under Section 90(13)

h) Before giving any information under Section 22 of the person to the

Nominated representative (information will be given to NR only if the PMI do not have capacity)

For treatment related decisions (other than admission) as per Section 4

Capacity Assessment for Treatment decisions including Admission

Name of the patient………………………………………………………………….. Age………………….. Sex…………………….. Patient ID No……………………………………………………………………………

Date of Assessment…………………………………..time………………………..

Place of Assessment ………………………………………………………………..

Purpose of this Assessment: Admission I Treatment / AD / Any Other

(If admitted under Section 102/103 of MHA, 2017 the rest of the assessment canhappen in the ward)

Advance Directive …………………………………………………..(Present/Absent)

Nominated Representative: Name:………………………………………………… ID:……………………………………………………..

Diagnosis (provisional)………………………………………………………………. Note: Provide explanation for each question

Obvious lack of capacity:

Is he/she in a condition, that that one cannot have any kind of meaningful conversation with

him/her (such as being violent, excited, catatonic, stuporous, delirious, under alcohol or substance intoxication/severe withdrawal, or any other (explain below))

(Yes / No)

If yes, then go to 4.If no, then go to 1.

1. Understandinq the information that is relevant to take a decision on the treatment or admission or personal assistance (Understands the nature and consequences of the decision; possible options explained)

a. Istheindividualorientedtotime,placeandperson?(Yes/No/Cannot assess)

Explanation:

b. Has he/she been provided relevant information about mental healthcare and treatment pertaining to the illness in question? (Yes / No)

If no, provide explanation:

c. Is he/she able to follow simple commands like (i) show your tongue (ii) close your eyes (Yes / No / Cannot assess)?

Explanation:

d. Does he/she acknowledge that he has a mental illness? (Yes / No / Cannot assess)

Explanation:

2. Appreciating reasonably foreseeable consequence of a decision or lackof decision on the treatment or admission or personal assistance.

a. Does the individual agree to receive treatment suggested by the treating team? (Yes / No / Cannot assess)

Explanation:

If yes, go to 2b. If no, go to 2c. If cannot assess, go to 3

b. Does he/she explain why he/she has agreed to receive treatment? (Yes / No / Cannot assess)

Explanation:

c. Does he/she explain why he/she does not agree to receive treatment? (Yes / No / Cannot assess)

Explanation:

3. Communicating the decision under sub-clause (1) by means of speech, expression, gesture or any other means (Specify).

a. Is the individual able to communicate his/her decision by means of speech, writing, expression, gesture or any other means? (Yes / No /Cannot assess)

Explanation:

4. Based on the examination and relevant history, behavioral observation, clinical findings and mental status examination findings noted in the medical records, I believe that Mr. / Ms………………………………………………(Strike off the choice that is not applicable)

a. Hascapacityfortreatmentdecisionsincludingadmission

b. Needs 100% support from his/her nominated representative in making

treatment decisions including admission

Signature of the Psychiatrist/Mental health professional/

Medical Practitioner …………………………………………………….. …… …….. ..

Name of the Psychiatrist/Mental health professional/

Medical Practitioner …………………………………………. …… ……..

5. Fill the following if the choice is 4.a.:

I, Mr. / Ms………………………………………………, agree to make decisions in respect of my mental healthcare and treatment.

Signature of the assessed person (if it is 4.a). Name of the assessed person:

6. Fill the following if the choice is 4.b.:

I, Mr. / Ms………………………………………………, the nominated representative of Mr. /Ms. …………………………………………………………….. agree to make dec/sions with respect of his/her treatment.

Signature of the Nominated Representative (if it is 4.b)……………………………… Name of the Nominated Representative:………………………………………………..

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Capacity Assessment for Treatment decisions including Admission

Name: Age/Sex: P.No.: Date/Time: Place of assessment: Advance Directive: Present/Absent

Purpose of this assessment: Admission/Treatment/Advance Directive/Any Other

(For admission under section 102/103 of MHCA 2017, rest of the assessment can happen in the ward)

Nominated Representative: Name: ID: Diagnosis (provisional):

Note: Provide explanation for each question

1. Understanding the information that is relevant to take a decision on the treatment or admission or personal assistance (Understands the nature and consequences of the decision; possible options explained)

Obvious

lack of

capacity

Is he/she in a condition, that that one cannot have any kind of meaningful conversation with him/her (such as being violent, excited, catatonic, stuporous, delirious, under alcohol or substance intoxication/severe withdrawal, or any other (explain below)) ………………….. ? (Yes/No)

If yes, then go to 4. If no, then go to 1.

A. Is the individual oriented to time, placeand person? (Yes/No/Cannot assess)

Explanation:

B. Has he/she been provided relevant information about mental healthcare and treatment pertaining to the illness in question? (Yes/No) If no, provide explanation:

C. Is he/she able to follow simple commands like (i) show your tongue (ii) close your eyes? (Yes/No/Cannot assess)? Explanation:

D. Does he/she acknowledge that he has amental illness? (Yes/No/Cannot assess) Explanation:

2. Appreciating reasonably foreseeable consequence of a decision or lack of decision on the treatment or admission or personal assistance.

A. Does the individual agree to receive treatment suggested by the treating team? (Yes/No/Cannot assess) Explanation:

If yes, go to 2b. If no, go to 2c. If

cannot assess, go to 3

B. Does he/she explain why he/shehas agreed to receive treatment? (Yes/No/Cannot assess) Explanation:

C. Does he/she explain why he/she does not agree to receive treatment? (Yes/No/Cannot assess) Explanation:

3. Communicating the decision as per question (1) by means of speech, expression, gesture or any other means(Specify).

A. Is the individual able to communicate his/her decision by means of speech, writing, expression, gesture or any othermeans? (Yes/No/Cannot assess)

Explanation:

4. Based on the examination and relevant history, behavioral observation, clinical findings and mental status examination findings noted in the medical records,

I believe that Mr./Ms. ……………………………(Strike off the choice that is not applicable) a. Has capacity for treatment decisions including admission

b. Needs 100% support from his/her nominated representative in making treatment decisions including admission

Name and Signature of the Psychiatrist/Mental health professional/ Medical Practitioner

5. Fill the following if the choice is 4.a.:

I, Mr./Ms. …………………………. , agree to make decisions in respect of my mental healthcare and treatment.

Name and Signature of the Patient Date………………………

6. Fill the following if the choice is 4.b.:

I, Mr./Ms. ……… …. ……………… …………….., the nominated representative of Mr./Ms. ………………………………….. agree to make decisions with respect of his/her treatment.

Name and Signature of the Nominated Representative Date……………………..

ADDITIONAL REFERENCES FOR CAPACITY ASSESSMENT

PART 2

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form C

Request for independent admission at NIMHANS, Bangalore-560029

To,

The Psychiatrist,

Unit –

NIMHANS, Bangalore

Sir/Madam,

Date:

Hospital No.

(MHCA 2017 Sec 86 & Rule 8)

I, Mr./Mrs./Ms.

age son/daughter of , residing at illness with following symptoms since

1. 2. 3.

have mental

The following papers related to my illness as available with me are enclosed: 1.

2. 3.

I wish to be admitted in your establishment for treatment and request you to please admit me as an independent patient.

Mr./Mrs/Ms , who is my

(specify relationship) will be staying with me during my admission period to help in the treatment process. A self-attested copy of my identity Proof is enclosed.

Alternative Mobil

List of enclosures:

N.B:- Please strike off those which are not required

.. .

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form E

Request for Admissions with High Support Needs at NIMHANS, Bangalore-560029

(MHCA 2017 Sec 89 and Rule 8)

To,

The Psychiatrist,

NIMHANS, Bangalore Sir/Madam,

admission in your establishment for treatment of mental illness.

symptoms since

1. 2. 3. 4. 5. 6.

Date:

tten Advance Directive.

The following papers regarding my appointment as nominated representative and information related to treatment of his/her mental illness are enclosed:

1. Advance Directive 2.

5. 6.

A self-attested copy of my identity Proof is also enclosed.

Kindly admit him/her in your mental health establishment as patient with high support needs.

. . ……… … .

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

To,

The Psychiatrist,

NIMHANS, Bangalore Sir/Madam,

(Institute of National Importance)

Form F

Request for Continuous Admissions with High Support Needs at NIMHANS, Bangalore-560029

(MHCA 2017 Sec 90 and Rule 8)

Date:

inpatient in your establishment under supported admission category, request for his/her continued admission beyond thirty days/readmission within seven days of discharge for the reasons stated below.

Kindly continue his/her admission /readmit him/her in your mental health establishment as patient with high support needs beyond thirty days.

A self-attested copy of my photo identity Proof is enclosed.

Alt

List of enclosures:

1) Copy of the self-attested photo ID proof

2) Copy of the Advanced Directives

3) 4)

5) 6) 7)

…

.. …

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form – G

REQUEST FOR DISCHARGE BY INDEPENDENT PATIENT

[MHCA 2017 Sec 88 and rule 8]

To,

The Psychiatrist,

NIMHANS, Bangalore Sir/Madam,

Subject: – Request for discharge.

Date:

admitted in your mental health establishment as an Independent admission patient on to be discharged. If any other

reason/s for discharge, please mention below

Kindly arrange to discharge me immediately.

N.B.:- Please strike off those which are not required

. .

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form – D

REQUEST FOR ADMISSION OF A MINOR

(u/s 87 of MHCA, 2017 and Mental Healthcare rules, 2018)

To,

The Medical Officer in-charge

Sir/Madam,

I, Mr. /Mrs. residing at _ , who is the

nominated representative (being legal guardian) of Master/Miss Master/Miss _ aged son/daughter of

He/she is having the following symptoms since 1.

2. 3.

_, request you to admit , for treatment of mental illness:

The following papers related to my being the nominated representative and his/her illness are enclosed: 1.

2. 3. 4.

Kindly admit him/her in your establishment as minor

patient.Address:

Mobile: E-mail: Date:

N.B.:- Please strike off those which are not required.

Signature of applicant Name of applicant

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form – H

(Adapted from The Mental Healthcare (Rights of persons with mental illness) rules, 2018)

REQUEST FOR DISCHARGE OF A MINOR BY ITS NOMINATED REPRESENTATIVE

To,

The Medical Officer in-charge

Sir/Madam,

Subject: – Request for discharge.

I am the nominated representative of Mr. /Ms. residing at

aged son/daughter of _ as a minor patient on . Mr./Ms. arrange to discharge him/her immediately.

Address Date Mobile Email

N.B.:- Please strike off those which are not required.

who was admitted in your mental health establishment now feel better and wish to be discharged. Kindly

Signature of the applicant Name of the applicant

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Application for NR for minors

(Application u/s 15 (2) of Mental Health Care Act of 2017) Particulars of the mental health establishment:

a) Name:

II.

b) E-mailId.

c) Contactnumber:

d) Dateofregistration e) Registerednumber:

Particulars of minor with mental illness:

a) Name:

b) Age/DateofBirth:

c) Nameofthefather:

d) Nameofthemother:

e) Dateofadmission:

f) Place of residence:

h) Hospital id:

III.

i) Aadhaar card number:

(NOTE: Aadhaar card Copy for

identification must be attached)

Particulars of the person who admitted the minor:

a) Name:

b) Male/ female

c) Age/DateofBirth:

d) Nameofthefather:

e) Placeofresidence:

f) Contact mobile number

g) Relationwiththeminor

h) Aadhaar card number:

(NOTE: Aadhaar card Copy for

identification must be attached) ParticularsoftheMentalHealthProfessionalwhosubmittedapplicationtotheBoardfor appointment of Nominated Representative for minor:

a) Name:

b) Designation

c) Registration number

d) Mobilecontactnumber: e) E-mailId

Particulars of person acting in the best interest of minor & wants to be NR

a) Name:

b) Male/Female:

c) Father’sName:

d) Placeofresidence:

e) Mobilecontactnumber:

f) E-Mail Id:

g) Aadhaar card number:

(NOTE: Aadhaar card Copy for identification must be attached)

Particulars of suitable individual person who is willing to act as nominated representative:

IV.

(If available, the name may be suggested by the applicant)

a) Name:

b) Male/ Female:

c) Father’sName:

d) Placeofresidence:

e) Mobilecontactnumber:

f) E-mail Id

g) Aadhaar card number:

(NOTE: Aadhaar card Copy for identification must be attached)

VI.

VII

VIII.

Therefore, for the above reasons the applicant requests for appointment of nominated representative for minor person with mental

illness………………………………………….. patient number …………………… as early as possible.

-: Certificate: –

I, hereby certify that the information furnished above are true and correct to the best of personal knowledge.

Evidence presented before the Board by the applicant to show that, legal guardian is not acting in the best interest of the minor to be attached.

Documentary evidence presented before the board by the applicant to show that, the legal guardian is otherwise not fit to act as the nominated representative of the minor to be attached.

Whether individual is available for appointment as nominated representative for the minor?

Place: Date:

Signature of the applicant Name of the applicant

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Permission for ECT for Minors

Application u/s 95 (2) of the Mental Healthcare Act of 2017) Particulars of the mental health establishment

a) Name:

b) E-mail Id.

c) Contact number:

d) Date of registration

e) Registered number:

II. Particulars of the mental health professional who is treating the minor with mental illness

a) b) c) d) e) f)

Name:

Designation Qualification Registration number Mobile contact Number

E-mail id

III. Particulars of minor who needs ECT:

a) Name:

b) Age/ Date of Birth:

c) Name of the father:

d) Name of the mother:

e) Date of admission:

f) Place of residence:

g) Name of the Department:

h) Hospital id:

i) Aadhaar card number:

NOTE: Aadhaar card Copy for identification must

be attached)

IV. Particulars of the natural/legal guardian (Mother or Father) who has given consent to perform

ECT.

a) Name:

b) Father’s name:

c) Mother’s name:

d) Age:

e) Relationship with minor:

f) Male/Female:

g) Contact number:

h) E-mail id:

i) Postal address:

NOTE: Aadhaar card Copy for identification must

be attached.

Particulars of the Nominated Representative for minor appointed by the Review Board who has given consent to perform ECT.

a) b) c) d) e) f) g)

Name:

Father’s name:

Mother’s name: Relationship with minor: Male/Female:

Contact number: E-mail id:

h) Postal address:

NOTE: Aadhaar card Copy for identification must be attached.

VI.

VII.

Whether giving ECT treatment for the minor is very much necessary and is un-avoidable?

If yes, the report with reasons must be attached.

Whether a copy of the written informed consent for ECT duly signed by the natural/legal guardian/nominated representative and the same is certified by the psychiatrist treating the minor is attached?

Therefore, for the above reasons the applicant requests for prior permission for Electro- Convulsive Therapy treatment for minor……………………………………….

patient number……………….as early as possible.

-: Certificate: –

I, hereby certify that the information furnished above are true and correct to the best of our personal knowledge.

Place Date

Signature of the applicant Name of the applicant

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form – I

REQUEST FOR LEAVE OF ABSENCE

(By Nominated Representative)

[MHCA 2017 Sec 91 and rule 9]

To, Date: The Psychiatrist,

NIMHANS, Bangalore

Sir/Madam,

Subject: – Request for leave of absence

I, as nominate

The proof of my appointment as nominated representative is enclosed. while he/she is on leave of absence from the mental health establishment.

. ..

Date & Time

N.B.:- Please strike off those which are not required.

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

APPLICATION FOR PSYCHOSURGERY

(Application u/s 96 of the Mental Healthcare Act of 2017 and under Regulation 17 of Mental Healthcare (Central mental HealthAuthority) Regulations, 2020)

Name of the mental health establishment.

Date of registration and registered number of mental health establishment.

Name of the medical officer who is treating the person with mental illness and his/her contact number and e-mail id.

Name of the mental health professional in charge of a mental health establishment and his/her contact number and e-mail id.

Name of the head of the department of psychiatry and his/her e-mail id and contact number:

Name of the medical superintendent and his/her e-mail id and contact number: Name of the qualified neurosurgeon who is performing psychosurgery.

Particulars of person who is undergoing psychosurgery:

a) Name:

b) Age:

c) Date of admission:

d) Department Name:

e) Patient No:

g) Aadhaar card for identification:

Consent of the patient to undergo psychosurgery taken or not

11.

12.

3. 4.

6. 7.

9. 10.

Name of the medical officer or mental health professional (qualified psychiatrist and neurosurgeons) who opined about the necessity of performing the psychosurgery.

Whether a certified copy of the written informed consent for psychosurgery duly signed by the person on whom it is proposedto be performed is enclosed along with the application?

Whether a detailed submission by the attending psychiatrist with clinical summaryof the case, explaining and justifying the need, suitability and safety of the proposed psychosurgery is enclosed along with the application?

Whether certified copies of such person’s 13. medical records are enclosed along with the

application? 14.

Therefore, for the above reasons, approval to perform psychosurgery procedure as a treatment for mental illness may kindly be granted.

-: Certificate: –

I, hereby certify that the information furnished in the above proforma are true and correct to the best of my personal knowledge.

Whether the mental health establishment is equipped with medical facilities and qualified neurosurgeons for undertaking the psychosurgery?

Place Date

Signature of the applicant Name of the applicant

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

FORM – A

(Central Mental Health Authority regulations, 2020)

FORM FOR MAKING, AMENDING/ REVOKING AND CANCELLING ADVANCE DIRECTIVE

1. Name (Attach copy of photo identity document proof):

2. Age (Attach copy of age proof for being above 18 years of age):

3. Father’s/ Mother’s Name:

4. Address (Attach copy of proof):

Note.- Any valid identity proof like Birth Certificate, Driving License, Voter’s Card, Passport, Aadhaar card, etc. shall be admissible as address proof and age proof.

5. Contact number(s):

6. Registration no. of previous advance directive (to be filled in case of amendment/ revocation/ cancellation of advance directive):

7. I wish to be cared for and treated as under (not to be filled in case of revocation/ cancellation of advance directive):

8. I wish not be cared for and treated as under (not to be filled in case of revocation/ cancellation of advance directive):

9. Any history of allergies, known side effects, or other medical problems

10. I have appointed the following persons in order of precedence(Enclosed photo ID and age proof), who are above 18 years of age to act as my nominated representatives to make decisions about my mental illness treatment, when I am incapable to do so (not to be filled in case of revocation/ cancellation of advance directive):

(a) Name: Father’s/Mother’s name:

Age

Address:

Contact number(s): Signature:………………………………………………………. Date

(b) Name: Age Father’s/Mother’s name:

Address:

Contact number(s): Signature:………………………………………………………. Date

[Any number of nominated representatives can be added]

11. Signature of applicant ……………………………………. Date

12. Signature of witnesses:

13. Mr./ Ms. has the mental capacity to make/ amend/ revoke/ cancel an advance directive at the time of signing this form and has signed it in our presence of his/ her own free will.

o Witness1:(Name)……………….(Signature)………….Date……… o Witness2:(Name)……………….(Signature)………….Date……..

Enclosure(s):

Note.- Please strike off those which are not required.

PART 3

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form-B

APPLICATION FOR GRANT OF PROVISIONAL REGISTRATION/ RENEWAL OF PROVISIONALREGISTRATION OF A MENTAL HEALTH ESTABLISHMENT

(SMHA Rules, 2018)

The………………………

Department of ……………….. State Government of …………………. ……………………………………….

Dear Sir/ Madam,

I/we intend to apply for grant of provisional registration/ permanent registration/ renewal

of provisional registration for the Mental Health Establishment namely ……………….. of which I am/we

are holding a valid licence/registration for the establishment/ maintenance of such hospital/nursing home. Details of thehospital/nursing home are given below:

1. 2.

3. 4. 5. 6.

7. 8.

Name of applicant ………………………………………………………………………………………….

Details of licence with reference to the name of the authority issuing the licence and date…………………………………………………………………………………………………………. ………………..

Age…………………………………………………………………………..

Professional experience in Psychiatry …………………………………………………………………..

Permanent address of the applicant …………………………………………………………………..

Location of the proposed hospital /nursing home ………………………………………………. ………………………………………………………………

Address of the proposed nursing home/hospital …………………………………. Proposed accommodations: ………………………………….

(a)Number of rooms …………………………………. (b) Number of beds …………………………………. (c)Facilities provided: …………………………………. (d) Out-patient ………………………………….

(e)Emergency services ………………………………….

(f) In-patient facilities ………………………………….

(g) Occupational and recreational facilities …………………………………. (h) ECT facilities (n X-Ray facilities ………………………………….

(i) Psychological testing facilities ………………………………….

(j) Investigation and laboratory facilities …………………………………. (k) Treatment facilities ………………………………….

Date

Staff pattern:

(a) Number of doctors …………………………………. (b) Number of nurses ………………………………….

I am herewith sending a bank draft for Rs……………… drawn in favour of

as application fee.

I hereby undertake to abide by the rules and regulation of the Mental Health Authority.

I request you to consider my application and grant the licence for establishment/ maintenance of psychiatrichospital/nursing home.

Yours faithfully Name Signature

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form-C

CERTIFICATE OF PROVISIONAL REGISTRATION/ RENEWAL OF PROVISONAL REGISTRATION

(SMHA Rules, 2018)

The State Authority, after considering the application dated…………..submitted by under section 65 (2)

or section 66 (3) or section 66(10) of the Mental Healthcare Act, 2017, hereby accords provisional registration/renewal of provisional registration to the applicant mental health establishment in terms of section 66 (4) or section 66 (11), as per the details given hereunder:

Name: Address _

No of beds_

The provisional registration certificate issued, is subject to the conditions laid down in the Mental Healthcare Act,2017 and the rules and regulations made there under and shall be valid for a period of twelve months from the date of its issue and can be renewed.

Place

Date

Registration authority

Seal of the registration authority

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form-B

APPLICATION FOR GRANT OF PROVISIONAL REGISTRATION/ RENEWAL OF PROVISIONALREGISTRATION OF A MENTAL HEALTH ESTABLISHMENT

(CMHA Rules, 2018)

India

………………………………………. Dear Sir/ Madam,

The……………………… Ministry/ Department Government of

I/we intend to apply for grant of provisional registration/ permanent registration/ renewal

of provisional registration for the Mental Health Establishment namely ……………….. of which I am/we

are holding a valid licence/registration for the establishment/ maintenance of such hospital/nursing home. Details of thehospital/nursing home are given below:

1. 2.

3. 4. 5. 6.

7. 8.

Name of applicant ………………………………………………………………………………………….

Age…………………………………………………………………………..

Professional experience in Psychiatry …………………………………………………………………..

Permanent address of the applicant …………………………………………………………………..

Location of the proposed hospital /nursing home ………………………………………………. ………………………………………………………………

Address of the proposed nursing home/hospital …………………………………. Proposed accommodations: ………………………………….

(a)Number of rooms ………………………………….

(b) Number of beds ………………………………….

(c)Facilities provided: ………………………………….

(d) Out-patient ………………………………….

(e)Emergency services ………………………………….

(f) In-patient facilities ………………………………….

(g) Occupational and recreational facilities ………………………………….

(h) ECT facilities (n X-Ray facilities ………………………………….

Staff pattern:

(i) Psychological testing facilities ………………………………….

(j) Investigation and laboratory facilities …………………………………. (k) Treatment facilities ………………………………….

(a) Number of doctors …………………………………. (b) Number of nurses ………………………………….

I am herewith sending a bank draft for Rs……………… drawn in favour of

I hereby undertake to abide by the rules and regulation of the Mental Health Authority.

I request you to consider my application and grant the licence for establishment/ maintenance of psychiatric hospital/nursing home.

Yours Faithfully Signature

Name

Date

as application fee.

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Form-C

CERTIFICATE OF PROVISIONAL REGISTRATION/ RENEWAL OF PROVISIONAL REGISTRATION

(CMHA Rules, 2018)

The Central Authority/ State Authority, after considering the application dated ……….. submitted

by ……………….. under section 65 (2) or section 66 (3) or section 66(10) of the Mental Healthcare Act, 2017, hereby

accords provisional registration/renewal of provisional registration to the applicant mental health establishment in termsof section 66 (4) or section 66 (11), as per the details given hereunder:

Name:

Address _ No of beds_

Place Date

Registration authority

Seal of the registration authority

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

FORM – C

APPLICATION FOR PERMANENT REGISTRATION OF A CENTRAL MENTAL HEALTH ESTABLISHMENT

(CMHA Regulations, 2020)

1. Name of the establishment:

2. Postal address:

3. Category:

4. Name, qualifications and experience of the in charge of the establishment:

5. Number of beds:

6. Past/ Current Registration No… ………………………………………. (Attach a copy)

(In case registration was under the Clinical Establishments (Registration and Regulation) Act, 2010 (23 of 2010) or any other law, such Registration No with a copy of Registration Certificate be enclosed with this application)

7. Services provided (tick what is provided)

(a) Out-patient

(b) In-patient

(d) Day Care

(e) Electroconvulsivetherapy

(f) Imaging

(g) Psychological testing

(h) Investigation and laboratory

(i) Any other (Specify)

8. Staff (Numbers):

(a) Medicalofficersandspecialists

(b) Para-medical/ para-clinical staff

(d) Health educators

(e) Multi-purposeworkers

(f) Others (Specify)

Details of registration fee paid:

DECLARATION

We hereby undertake to abide fully by the provisions of the Mental Health Care Act, 2017 (10 of 2017) and rules and the regulations made thereunder.

CONFIRMATION

We confirm that our establishment complies with the minimum standards specified under the Central Mental Health Authority Regulations, 2020 under which we are seeking registration.

PRAYER

We request for registration of our mental health establishment with the Authority.

Date Signed by the authorized signatory (Name and designation of the signatory

Place Stamp of the mental health establishment

Enclosure:

PART 4

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Independent Opinion of a Psychiatrist/ Medical practitioner/ Medical Officer in charge for Admission

(Under Sec 89 or 90 of MHCA 2017)

–

sought information of the history of presenting illness, examined personally and independently

Please tick the appropriate choice below and provide explanation:-

1. has recently threatened or attempted or is threatening or attempting to cause bodily harm to himself or

2. has recently behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him; or

3. has recently shown or is showing an inability to care for himself to a degree that places the individual at risk of harm to himself

Explanation for the choice/s

requires supported admission under Sec 89 or 90.

Name & Signature of the Psychiatrist Medical practitioner/

Medical Officer in charge

Date: ..

N.B.:- Please strike off those which are not required.

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

INTIMATION OF ADMISSION OF PERSON WITH MENTAL ILLNESS TO THE MENTAL HEALTH REVIEW BOARD

(u/s 87, 89 of MHCA, 2017)

I) Particulars of the person with mental illness admitted in the Mental Health Establishment

a) b)

c) d)

Name : Father’s Name : Age : Male/Female : Place of Residence : Mobile Contact No. : E-mail I.D (if any. : Aadhaar Card No. : Patient No. : Date of Admission :

II) Particulars of nominated representative

a) Name :

b) Father’s Name :

c) Age :

d) Male/Female :

e) Place of Residence :

f) Mobile Contact No :

g) E-mail ID (if any) :

h) Aadhaar Card No :

i) Relationship with patient : (Ref: Sec. 14 of MHC Act, 2017)

III) Particulars of mental health establishment

a) Name

b) E-mail ID

c) Contact No

d) Registration no. of Establishment

e) Date of Registration

f) Name of the Mental health

professional in charge of the mental health establishment.

: NIMHANS, Bengaluru

: ms@nimhans.ac.in

: 080-26995201

: CMHA/2024/0001

: 13/3/24

: Medical Superintendent NIMHANS, Bengaluru

IV Admission of minor

Whether admission is intimated to the Board within 72 hours as required u/s 87(9) of the Act?

V Supported admission of Minor/Woman up to thirty days Whether admission of minor/women is reported to the Board within three days of admission as required u/s 89(9)(a) of the Act?

VI Continuous admission of minor

Whether continuous admission of minor for a period of thirty days is

immediately informed to the Board as required u/s 87[11] of the Act?

VII Supported admission up to thirty days of any person

Whether “any person not being a woman or minor is reported to the Board within seven days of admission as required u/s 89(9)(b) of the Act?

CERTIFICATE

I hereby certify that, the above information provided in the proforma are true and correct to the best of my personal knowledge and based on the clinical/medical records maintained in this mental health establishment.

Place: NIMHANS, Bengaluru Date:

Senior Resident

(With seal and Signature)

Mental health charge of the establishment

professional in mental health

I. a.

II. a.

b. c. d. e. f.

III.

a. b. c.

a. b.

(Institute of National Importance)

Application seeking permission for continuation of admission or readmission or discharge of person with mental illness with high supported needs beyond thirty days. (u/s 90 (5) of the Mental Healthcare Act of 2017 seeking)

Particulars of Mental Health Establishment:

Name of the mental health establishment:

Date of Registration and registered number of mental health establishment:

Particulars of the person with mental illness:

Name of the person with mental illness:

Date of birth of person with mental illness: Male/Female:

Date of admission:

Department Name:

Patient No:

Address:

(Aadhaar card has to be enclosed) Contact no:

Particulars of Nominated Representative:

Name: Age:

Male/Female:

Address:

(Aadhaar card has to be enclosed)

Relationship with the person with mental health illness:

Contact no:

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

Name of the medical officer who is treating the person with mental illness and his/her contact number and e-mail id:

Name of the mental health professional in charge of a mental health establishment and his/her contact number and e-mail id:

Particulars of information furnished by the medical officer or mental health professional for seeking permission for continuation:

Name of the medical officer or mental health professional who has assessed and evaluated and diagnosed the illness:

Date of admission and treatment with high supported needs up to thirty days:

Whether admission or readmission u/s 90 (3) is reported to the Review Board within seven days from the date of admission.

Date of application by the Nominated Representative u/s 90 (2) of the Act for seeking continuation beyond thirty days with high supported needs.

(Copy of the application of NR must be enclosed)

Whether admitted person under section 89 of the Act requires continues high supported treatment beyond thirty days?

Whether two psychiatrists have independently examined the person with mental illness in the preceding seven days? (Copy of medical records must be enclosed)

Whether two psychiatrists independently conclude based on the examination and, on information provided by others that the person has illness of severity that the person-

i) has consistently over time threatened or attempted to cause bodily harm to himself; or

ii) has consistently over time behaved violently towards another person or has consistently over time caused another person to fear bodily harm from him; or

iii) has consistently over time shown an inability to care for himself to a degree that places the individual at risk of harm to himself?

(Enclose copies of the medical records examined by above two psychiatrists)

Whether both psychiatrists after taking into account an advanced directive, if any, certify that admission to a mental health establishment is the least restrictive care option possible under the circumstances?

Whether person continues to remain ineligible to receive care and treatment as an independent patient as the person cannot make mental healthcare and treatment decisions independently and needs very high support from his nominated representative, in making decisions? If yes, give reasons.

Whether following copies of the medical records are enclosed along with application to examine:

a) the need for institutional care to person

b) whether such care cannot be provided in less restrictive settings based in the community?

Whether copy of the plan for community- based treatment and the progress made or likely to be made, towards realising said plan is submitted to the review Board?

Therefore, for the above reasons, permission for continuation of admission/readmission/discharge of person with mental illness with high supported needs beyond thirty days u/s 90 (5) may kindly be granted.

-: Certificate: –

We hereby certify that the above information’s provided in the proforma are true and correct to the best of our personal knowledge and based on the clinical/medical records maintained in this medical health establishment.

Place Medical officer/mental health professional Date

(with seal and signature)

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Application submitted to the Mental health review Board u/s 93 and 103 of Mental Healthcare Act of 2017 for seeking transfer of prisoner with mental illness from one mental health establishment to another mental health establishment within the State or outside the State.

Name of the mental health establishment seeking transfer of prisoner with mental illness. Name of the receiving mental health establishment of prisoner with mental illness.

Date of Registration and registered number of 4. mental health establishment seeking transfer of

prisoner with mental illness.

Date of registration and registration number of

mental health establishment receiving the prisoner with mental illness.

Name of the medical officer who is treating the

6. prisoner with mental illness and his/her contact

number and e-mail id.

Name of the mental health professional in charge

7. of a mental health establishment and

his/her contact number and e-mail id:

8. Name of the prisoner with mental illness:

9. Date of birth of prisoner with mental illness:

10. Male/Female:

11. Date of admission:

12. Department Name:

13. Patient No:

14.

15.

16.

Whether service of psychiatrist in the receiving 17. mental health establishment for treating the

prisoner with mental illness is available?

Whether mental health establishment which intends to receive the prisoner with mental illness is equipped with necessary medical facilities for treatment?

1. 2.

Name of the medical officer/mental health professional in charge of the mental health establishment receiving prisoner with mental illness and his/her contact number and e-mail id.

Whether prisoner with mental illness admitted in mental health establishment is:

a) Under section 89 or

b) Under section 90 or

c) Under section 103?

Whether service of psychiatrist for treating the prisoner with mental illness is available in the mental health establishment which intends to transfer?

Whether mental health establishment which intends to transfer the prisoner with mental illness is equipped with necessary medical

facilities for treatment?

18.

What are the reasons for seeking transfer of

prisoner with mental illness to other mental health

establishment?

(detailed reasons has to be assigned)

Whether transfer of prisoner with mental illness to another mental health establishment is ordered by

the court? (enclose copy of the court order)

Whether review Board has issued any general or

special order for removal of person with mental

illness within the State?

(If yes, enclose copy of the order)

Whether review Board with the consent of the Central Authority has issued any general or special order for transfer of prisoner with mental illness to

any other State?

(If yes, enclose copy of the order)

19. 20. 21.

22.

23.

24.

Whether there is any provision for psychiatric 25. ward in the medical wing of the prison or jail for

prisoner with mental illness? 26.

27.

Whether intimation and reasons for transfer has been given to the prisoner with mental illness?

Whether intimation and reasons for transfer has been given to the prisoner to his nominated representative appointed u/s 14 of Mental

Healthcare Act of 2017.

(copy of the intimation enclosed)

Whether quarterly report is submitted to the Board certifying therein that there are no prisoners with the mental illness in the prison

or jail?

The method, modalities and procedure by which the

transfer of a prisoner is to be effected.

(If prescribed, enclose the copy of the same.)

Therefore, for above reasons, permission for transfer of prisoner with mental illness may kindly be granted.

: Certificate: –

We hereby certify that, the information furnished in the above proforma are true and correct to the best of our personal knowledge and based on the clinical/medical records maintained in this medical health establishment.

Mental health professional In charge of mental health Establishment

Place Date

Name and signature of the jail superintendent

(Seal)

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

Name of the Patient:

Sex: Age: File No:

Date:

Provisional Diagnosis: Date of Admission:

(Institute of National Importance)

FORM – E

Physical Restraint Monitoring and Reporting Form (CMHA Regulations, 2020)

Indication for Physical Restraint (encircle): (1) Violence (2) Agitation (3) Aggression (4) Self- harm (5) Suicidal attempt (6) Other (specify)…………………………………

Informed Consent of the Nominated Representative taken: Yes/ No Name and Signature of the Nominated Representative: If informed If Consent not taken, mention the reason:

Date and Time of Physical Restraint:

Date Time

From To

Overall assessment of medical conditions of the person under physical restraint including injuries, blood supply to limbs, blood pressure, pulse, etc. or any other relevant parameter:…………………………………………………………………….

Mention the dose and frequency of medications administered during the Physical Restraint: Medication Dose Route Frequency Total dose Side-effects

Name, Signature and Seal of the person in-charge of the mental health establishment:

PART 5

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Basic Medical Record of all out-patients (at hospitals, nursing homes, private clinics, camps, mobile clinics, primary health care centers and other community outreach programmes, and the like matters):

(In hard copy format)

(a) Nameofthementalhealthestablishment/doctor

(b) Date

(d) Advance Directive YES/NO

(e) Patient’s Name

(f) Age Sex

(g) Father’s/Mother’s name

Mobile No

(h) Chief complaints

(i) Provisional diagnosis

(j) Treatment advised and follow-up recommendations.

Address

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Basic Medical Record of In-Patient

a. Name of the hospital/nursing home

b. Date

c. Patient’s name

d. Father’s/Mother’s name

e. Age Sex

f. Address

g. Patient accompanied by (Name, age and nature of relationship)

h. Hospital registration number

i. Identification marks

j. Nominated representative

k. Advanced Directive – Yes or No; If yes salient features of the content

l. Date of admission Date of discharge

m. Mode of admission (section of the Mental Healthcare Act, 2017): Independent/ Supported

n. Chief complaints

o. Summary of Medical Examination Laboratory investigations

p. Provisional/differential/ final diagnosis

q. Course in the hospital (Treatment and Progress)

r. Condition at discharge or discharge at request or leave against medical advice or person with mental illness absconding or others

s. Treatment advice at discharge

t. Follow-up recommendations

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Basic Psychological Assessment Report (facilities where persons with mental illness undergoes psychological assessment):

Clinic Record no. ————————————-

Name: Age:

Education: Occupation: Referred by:

Reason for referral: IQ assessment

Specific learning disability assessment

Neuropsychological assessment (Specify domain if the assessment is domain specific) Personality assessment

Psychopathology assessment

Any other (Mention the specific domain such as interpersonal relationship)

Comments if any (may give brief detail of the referral purpose; e.g., ‘the individual has mental illness and he has been referred for current psychopathology assessment as well as to ascertain the level of disability’)

Brief background information (e.g., the nature of the problem, when it started, any previous assessments and like details):

Informant: Self Others Specify

Salient behavioral observations (Comment on alertness, attention, cooperativeness, affect, comprehension and any other relevant information)

Tests/ Scales administered (Standardized tests/ scales):

Gender: Date of testing: Language tested in:

Salient scores (if applicable such as Intelligence Quotient, scores obtained on cognitive function tests, severity rating on psychopathology scales, disability percentage and like details)

Impression: Recommendations: Further assessment Specify Therapy Specify

Any other Specify

Assessed by Name:

Date: Qualification: Signature:

Verified/ supervised by (if applicable) Name:

Date:

Qualification:

Signature:

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Basic Minimum Standard Guidelines for Recording of Therapy Report (facilities where persons with mental illness are provided with therapy for any mental health problem)

Minimum Basic Standard Guidelines for Recording of Therapy (Name of the Institute/Hospital/Centre with address)

Clinic record no._____________

Patient name:

Age:

Gender:

Psychiatric diagnosis:

Therapy method: Individual Couple/Family Group

Other

Objectives of the session: 1.

THERAPIST SESSION NOTES

Session number and date:

Duration of session:

Session Participants:

Key issues/themes discussed: (Psychosocial stressors/Interpersonal problems/Intrapsychic conflicts/Crisis situations/Conduct difficulties/Behavioral difficulties/ Emotional difficulties/ Developmental difficulties/ Adjustment issues/ Addictive behaviours/ Others).

Therapy techniques used:

Therapist observations and reflections:

Plan for next session:

Date for next session:

Therapist Name:

Date: Qualification: Signature:

Supervised by (if applicable) Name:

Date:

Qualification:

Signature:

PART 6

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

APPLICATION FOR ASSSESSMENT/ADMISSION OF ANY PERSON FOUND WANDERING AT LARGE WITH MENTAL ILLNESS

(Application u/s 100 of MHCA, 2017)

Particulars of the person found wandering at large with mental illness

a) Name:

b) Fathers name:

c) Age:

d) Address: (If any)

e) Male/Female:

f) Contact number: (If any)

2. Particulars of the police station and duties performed by the Police Officer: a) Police station

b) Contact number: c) E-mail- id:

e) Date and time of taking homeless and wandering person for protection.

f) Date and time of taking such person to the nearest public health establishment:

g) Place where person found at large:

h) Whether first information report (FIR) of

missing person is lodged?

i) Whether station house officer (SHO) has made any efforts to trace the family of such person and informed the family aboutwhere abouts?

Therefore, for the above reasons the applicant requests for assessment/admission of the patient……………………………………….

Hospital id ……………………as early as possible.

-: Certificate: –

I, hereby certify that the information furnished above are true and correct to the best of my personal knowledge.

d) Officer in charge of the police station (Name, designation, ID number, contact number, email id)

Place Date

Signature Name

Police Station Police ID No.

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Request for appointment of nominated representative of the person with mental illness who is HOMELESS or FOUND WANDERING AT LARGE (Section 100, 14, 15 & 17).

Particulars of the person found homeless or wandering at large with mental illness:

a) Name:

b) Fathers name:

c) Age:

d) Address: (If any)

e) Male/Female:

f) Contact number: (If any)

2. Particulars of public health establishment:

a) Name:

b) Address:

c) Contact number:

d) E-mail-id:

f) Contact number of medical officer:

3. Particulars of a Government establishment for homeless persons:

a) Name:

b) Name of the administrator:

c) Contact number:

d) E-mail id:

e) Address:

f) Name of the doctor/psychiatrist: (If any)

4. Particulars of the police station and duties performed by the Police Officer:

e) Name of the medical officer who has arranged the assessment of the person and the needs of the person with mental illness:

g) If medical officer in charge of public health establishment, after assessment, found such person suffering from mental illness, whether such person is admitted for the treatment and reported the same matter to

the Board as required u/s 87 or 89 of the Act as the case may be?

a) b) c) d)

f) g) h)

Name/Address:

Contact number:

E-mail- id:

Date of taking homeless and wandering person for protection.

Dateandtimeoftakingsuchpersontothe nearest public health establishment: Place where person found at large:

Officer in charge of a police station:

Whether grounds of taking into protection is informed to such person or his nominated representative?

i) Whether such person is taken by police officer to the nearest public health establishment within 24 hours for assessment of person’s health care needs?

j) Whether such person taken into protection is detained in the police lockup or prison?

k) Whetherfirstinformationreport(FIR)of missing person is lodged?

m) What is the report of police officer about the such person’s residence?

l) Whether station house officer (SHO) has made any efforts to trace the family of such person and informed the family about where abouts?

Whether the medical officer after collecting the above authentic information has filed this application to the Board for appointing a nominative representative of a person with mental illness u/s 14 (4) and

15 of the Mental Healthcare Act of 2017?

Place: Date:

Therefore, the undersigned medical officer/ mental health professional in charge of public health establishment for above reasons, prays for seeking order of appointment of nominated representative of the person with mental illness who is homeless or found wandering at large.

Certificate: –

I hereby certify that, the information furnished in the above proforma are true and correct to the best of my personal knowledge and on the clinical/medical records maintained in this medical health establishment and based on the information furnished by the police officer.

Medical office/Mental health professional, in charge of mental health establishment.

(with seal and signature)

NATIONAL INSTITUTE OF MENTAL HEALTH AND NEURO SCIENCES, BANGALORE-29

(Institute of National Importance)

Application submitted for filing of FIR by police under section 100 of MHCA 2017 of the person with mental illness who is HOMELESS or FOUND WANDERING AT LARGE (Section 100 of the Act).

Particulars of the person found homeless or wandering at large with mental illness:

a) Name:

b) Fathers name:

c) Age:

d) Address: (If any)

e) Male/Female:

f) Contact number: (If any)

2. Particulars of public health establishment:

a) Name:

b) Address:

c) Contact number:

d) E-mail-id:

f) Contact number of medical officer:

3. Particulars of the police station a) Name/Address:

b) Contact number:

c) E-mail- id:

Therefore, the undersigned medical officer/ mental health

professional in charge of public health establishment for above reasons, prays for filing of FIR by police under section 100 of MHCA 2017 of the person with mental illness who is homeless or found wandering at large.

Certificate: –

Medical office/Mental health professional, in charge of mental health establishment.

(with seal and signature)

e) Name of the medical officer who has arranged the assessment of the person and the needs of the person with mental illness:

the Board as required u/s 87 or 89 of the Act as the case may be?

Place: Date:

SECTION 100 (MHCA, 2017)