HOSPITAL ADMISSION FORMS g S.L.262.01 1
SUBSIDIARY LEGISLATION 262.01
HOSPITAL ADMISSION FORMS REGULATIONS
14th August, 1981
LEGAL NOTICE 90 of 1981.
Title.
Forms Regulations.
Prescribed forms.
observation under articles 14 and 16 of the Mental Health Act,
hereinafter referred to as "the Act", shall be the form shown in the
First Schedule.
(2) The form for emergency application for admission to a
hospital for observation under articles 15 and 16 of the Act shall be
the form shown in the Second Schedule.
(3) The form for a medical recommendation for admission to a
hospital for observation under articles 14, 15 and 17 of the Act
shall be the form shown in the Third Schedule.
(4) The form for a joint medical recommendation for
admission to a hospital for observation under article 14 of the Act
shall be the form shown in the Fourth Schedule.
(5) The form for application by a nearest relative for
admission to a hospital for treatment under articles 14 and 16 of the
Act shall be the form shown in the Fifth Schedule.
(6) The form for application by a mental welfare officer for
admission to a hospital for treatment under articles 14 and 16 of the
Act shall be the form shown in the Sixth Schedule.
(7) The form for a medical recommendation for admission to a
hospital for treatment under article 14 of the Act shall be the form
shown in the Seventh Schedule.
(8) The form for a joint medical recommendation for
admission to a hospital for treatment under article 14 of the Act
shall be the form shown in the Eighth Schedule.
(9) The form for a report on a hospital in-patient in accordance
with article 18 of the Act shall be the form shown in the Ninth
Schedule.
(10) The form for the renewal of authority for detention in a
hospital in accordance with article 21(4) of the Act shall be the
form shown in the Tenth Schedule.
(11) The form for a report barring the discharge by a nearest
relative in accordance with article 29 of the Act shall be the form
shown in the Eleventh Schedule.
2 g S.L.262.01 HOSPITAL ADMISSION FORMS
FIRST SCHEDULE
MENTAL HEALTH ACT
Application for Admission for Observation (Articles 14 and 16)
(This application is valid only for 14 days beginning with the date appearing on
the medical recommendation given as the date on which the patient was last
examined by the medical practitioner before giving that recommendation.)
(1) Name and address
of hospital.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name and address
of applicant.
1. I (2) ............................................................
of ............................................................................
hereby apply for the admission of (3) ......................
................................. of ...................................... to
the above-named hospital for observation in
accordance with Part III of the Mental Health Act.
(3) Name and address
of patient.
(4) State relationship. 2. ( a ) I am the patient’s nearest relative within
the meaning of the Act, being the patient’s (4) ....... .
OR
(5) Copy of Court
order.
( b ) I have been authorised by the Court to
exercise the functions of the patient’s nearest
relative under the Act and a copy (5) of the authority
is attached to this application.
OR
( c ) I am appointed to act as mental welfare
officer for the purpose of the Act.
3. I last saw the patient on .............. (must not
be later than 14 days from date of application).
4. This application is founded on the medical
recommendation/s forwarded herewith.
(6) If neither of the
medical practitioners who
have made the medical
recommendations had
previous acquaintance with
the patient, the applicant
should state here why it is
not practicable to obtain a
recommendation from a
practitioner having such
acquaintance.
5. (6) .............................................................
................................................................................
................................................................................
................................................................................
Signed ........................
Date ........................
Record of Admission
(This is not part of the application, but is to be completed later at the hospital)
HOSPITAL ADMISSION FORMS g S.L.262.01 3
(7) Name of patient. ( a ) (7) ........................................... was admitted
to (8) ................................................... in
pursuance of this application at ...................... .
OR
( b ) (7) ......................... was already an in-patient
in (8) ......................... on the date of this application
and the application was received by me on behalf of
the manager on ........................ .
(8) Name of hospital.
Delete ( a ) or ( b )
Signed ........................
on behalf of the manager
Date ........................
4 g S.L.262.01 HOSPITAL ADMISSION FORMS
SECOND SCHEDULE
MENTAL HEALTH ACT
Emergency Application for Admission for Observation
(Articles 15 and 16)
(This application is valid for 2 days beginning with the date appearing on the
medical recommendation as the date on which the patient was last examined by a
medical practitioner before giving that recommendation.)
(1) Name and address
of hospital.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name and address
of applicant.
1. I (2) ............................................................
of ............................................................................
hereby apply for the admission of (3) ......................
............................... of ............................................
...................................................................... to the
above-named hospital for observation in accordance
with Part III of the Mental Health Act.
(3) Name and address
of patient.
 
(4) State relationship. 2. ( a ) I am a relative of the patient within the
meaning of the Act, being the patient’s (4) ............ .
OR
( b ) I am appointed to act as a mental
welfare officer for the purposes of the Act.
3.  I last saw the patient on .............. (must not
be later than 3 days from date of application).
4. In my opinion it is of urgent necessity for
the patient to be admitted and detained under article
15 of the Act, and compliance with the requirements
of the Act relating to applications for admission
other than emergency applications would involve
undesirable delay.
5. This application is founded on the medical
recommendation forwarded herewith.
(5) If the medical
practitioner who has made
the recommendation had no
previous acquaintance with
the patient, the applicant
should state here why it is
not practicable to obtain a
recommendation from a
practitioner having such
acquintance.
6. (5) .............................................................
................................................................................
................................................................................
................................................................................
Signed ........................
Date ........................
Record of Admission
(This is not part of the application, but is to be completed later at the hospital)
HOSPITAL ADMISSION FORMS g S.L.262.01 5
(6) Name of patient. ( a ) (6) .................................. was admitted to (7)
............................... in pursuance of this application
at (8) ................. on ........................
OR
( b ) (6) ......................... was already an in-patient
in (7) ......................... on the date of this application
and the application was received by me on behalf of
the manager at (8) ....................... on ......................
(7) Name of hospital.
(8) Time and date.
Delete ( a ) or ( b )
Signed ........................
on behalf of the manager
Date ........................
6 g S.L.262.01 HOSPITAL ADMISSION FORMS
THIRD SCHEDULE
MENTAL HEALTH ACT
Medical Recommendation for Admission for Observation
(Articles 14, 15 and 17)
(1) Name and address
of medical practitioner.
1. I (1) ....................................................... of
....................................... being a registered medical
practitioner recommend that (2) .......................... of
................................................................................
be admitted to hospital for observation in
accordance with Part III of the Mental Health Act.
(2) Name and address
of patient.
2. I last examined the patient on ................
* Delete if not applicable. 3. *( a ) I was acquainted with the patient
previously to conducting that examination.
*( b ) I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
4. I am of the opinion -
( a ) that this patient is suffering from mental
disorder of a nature or degree which warrants his/
her detention in a hospital under observation for at
least a limited period,
AND
( b ) that this patient ought to be so detained:
Delete (i) or (ii) unless
both apply.
(i) in the interests of the patient’s own
health or safety,
(ii) with a view to the protection of
other persons.
5. (This section is to be deleted unless the
medical recommendation is the first
recommendation in support of an emergency
application under article 15)
In my opinion it is of urgent necessity for the
patient to be admitted and detained under article 15
of the Act and compliance with the requirements of
the Act relating to applications for admission for
observation other than emergency application would
involve undesirable delay.
Signed ........................
Date ........................
Record of Receipt
(This is not part of the recommendation, and is to be completed only if the medical 
recommendation is the second recommendation in support of an emergency 
application under article 15)
HOSPITAL ADMISSION FORMS g S.L.262.01 7
ARTICLE 17(3) MENTAL HEALTH ACT
This medical recommendation shall not be given by any of the following
persons:
( a ) applicant;
( b ) a partner of the applicant or of a practitioner by whom another medical
recommendation is given for the purpose of the same application;
( c ) a person employed by the applicant or by any such practitioner as
aforesaid;
( d ) a person who receives or has an interest in the receipt of any payments
made on account of the maintenance of the patient; or
( e ) the husband or wife or a relative by consanguinity or affinity up to the
second degree of the patient, or of any such person as aforesaid or of a
practitioner by whom another medical recommendation is given for the
purpose of the same application.
(3) Insert time and
date.
This recommendation was received on behalf of
the manager at (3) ........................ on ......................
the patient having been admitted at (3) on ................
Signed ........................
on behalf of the manager
Date ........................
8 g S.L.262.01 HOSPITAL ADMISSION FORMS
FOURTH SCHEDULE
MENTAL HEALTH ACT
Joint Medical Recommendation for Admission for Observation
(Section 14)
(1) Names and
addresses of both medical
practitioners.
1. We (1) ........................................................
of ..................................................................... and
....................................... of ....................................
................................................................................
being registered medical practitioners recommend
that (2) ................. of ..............................................
be admitted to a hospital for observation in
accordance with Part III of the Mental Health Act.
(2) Name and address
of patient.
(3) Name of first
practitioner.
2. ( a ) I (3) ................................ last examined
this patient on ......................
* Delete if not applicable. *( b ) I was acquainted with the patient
previously to conducting that examination.
*( c ) I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
(4) Name of second
practitioner.
3. ( a ) I (3) ................................ last examined
this patient on ......................
* Delete if not applicable. *( b ) I was acquainted with the patient
previously to conducting that examination.
IMPORTANT: Medical
practitioners must have
personally examined the
patient, either together or at
an interval of not more than
3 days.
*( c ) I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
(5) Names of both
practitioners.
4. We (5) ................................................. and
........................... are of the opinion -
( a ) that this patient is suffering from mental
disorder of a nature or degree which warrants his/
her detention in a hospital under observation for at
least a limited period,
AND
( b ) hat this patient ought to be so detained:
(i) in the interests of the patient’s own
health or safety,
(ii) with a view to the protection of
other persons.
Signed ........................
Date ........................
Signed ........................
Date ........................
HOSPITAL ADMISSION FORMS g S.L.262.01 9
ARTICLE 17(3) MENTAL HEALTH ACT
This medical recommendation shall not be given by any of the following
persons:
( a ) applicant,
( b ) a partner of the applicant or of a practitioner by whom another medical
recommendation is given for the purpose of the same application;
( c ) a person employed by the applicant or by any such practitioner as
aforesaid;
( d ) a person who receives or has an interest in the receipt of any payments
made on account of the maintenance of the patient; or
( e ) the husband or wife or a relative by consanguinity or affinity up to the
second degree of the patient, or of any such person as aforesaid or of a
practitioner by whom another medical recommendation is given for the
purpose of the same application.
10 g S.L.262.01 HOSPITAL ADMISSION FORMS
FIFTH SCHEDULE
MENTAL HEALTH ACT
Application by Nearest Relative for Admission for Treatment
(Articles 14 and 16)
(This application is valid only for 14 days beginning with the date appearing on the 
medical recommendation as the date on which the patient was last examined by 
medical practitioner before giving that recommendation.)
(1) Name and address
of hospital.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name and address
of applicant.
1. I (2) ........................................................ of
................................................................................
hereby apply for the admission of (3) ......................
............................... of ............................................
...................................................................... fl-to
the above-named hospital for treatment in
accordance with Part III of the Mental Health Act,
as a patient suffering from
(3) Name and address
of patient.
(4) Insert mental
illness, severe subnormality,
subnormality and/or
psychopathic disorder.
(4) .......................................................................
(5) State relationship. 2. ( a ) I am the patient’s nearest relative within
the meaning of the Act, being the patient’s (5) ....... .
Delete ( a ) or ( b ) OR
(6) Copy of the Court
order or form of authority
signed by the nearest
relative.
( b ) I have been authorised by the Court/the
patient’s nearest relative to exercise the functions of
the patient’s nearest relative under the Act and a
copy of (6) the authority is attached to this
application.
3. I last saw the patient on ............ (must not
be later than 14 days from date of application).
4. (This section is to be deleted if the patient is
recorded above as suffering from mental illness or
severe subnormality).
The patient’s date of birth is ........................
5. This application is founded on the medical
recommendations forwarded herewith.
(7) If neither of the
medical practitioners who
have made the medical
recommendations had
previous acquaintance with
the patient the applicant
should state here why it is
not practicable to obtain a
recommendatian from a
practitioner having such
acquaintance.
6. (7) .............................................................
................................................................................
................................................................................
................................................................................
Signed ........................
Date ........................
HOSPITAL ADMISSION FORMS g S.L.262.01 11
Record of Admission
(This is not part of the application, but is to be completed later at the hospital)
(8) Name of patient. ( a ) (8) ........................................... was admitted
to (9) .............................. in pursuance of this
application on ...................... .
OR
( b ) (8) ..................................... was already in
(9) ............................ on the date of this application
and the application was received by me on behalf of
the manager on ........................ .
(9) Name of hospital.
Delete ( a ) or ( b )
Signed ........................
on behalf of the manager
Date ........................
12 g S.L.262.01 HOSPITAL ADMISSION FORMS
SIXTH SCHEDULE
MENTAL HEALTH ACT
Application by a Mental Welfare Officer for Admission
for Treatment
(Articles 14 and 16)
(This application is valid only for 14 days beginning with the date appearing on
the medical recommendation as the date on which the patient was last examined by
medical practitioner before giving that recommendation.)
(1) Name and address
of hospital.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name and address
of applicant.
1. I (2) ............................................................
of ............................................................................
hereby apply for the admission of (3) ......................
................................. of ..........................................
...................................................................... to the
above-named hospital for treatment in accordance
with Part III of the Mental Health Act, as a patient
suffering from
(3) Name and address
of patient.
(4) Insert mental
illness, severe subnormality,
subnormality and/or
psychopathic disorder.
(4) .......................................................................
2. (This section should be deleted if no
consultation has taken place).
( a ) I have consulted ................. of ...................
who to the best of my knowledge and belief is the
patient’s nearest relative within the meaning of the
Act.
OR
( b ) I have consulted ................ of ....................
who has been authorised by the Court to exercise the
functions of the patient’s nearest relative under the
Act.
OR
( c ) I have consulted ................ of ....................
who has been authorised by ..................... who to
the best of my knowledge and belief is the patient’s
nearest relative within the meaning of the Act, to
exercise the functions of the patient’s nearest
relative under the Act.
AND
she/he has not notified me that she/he objects to this
application being made.
3. (This section should be deleted if
consultation has taken place).
( a ) I have been unable to ascertain who is the
patient’s nearest relative within the meaning of the
Act.
HOSPITAL ADMISSION FORMS g S.L.262.01 13
OR
( b ) To the best of my knowledge and belief this
patient has no nearest relative within the meaning of
the Act.
OR
( c ) In my opinion it is not reasonably
practicable/would involve unreasonable delay
before making this application to consult
........................... of ...............................................
who to the best of my knowledge and belief is this
patient’s nearest relative within the meaning of the
Act/authorised to exercise the functions of this
patient’s nearest relative under the Act.
4. I last saw the patient on .............. (must be
not later than 14 days from date of application).
5. (This section is to be deleted if the patient is
recorded above as suffering from mental illness or
severe subnormality.)
The patient’s date of birth is ........................
6. This application is founded on the medical
recommcndations forwarded herewith.
(5) If neither of the
medical practitioners who
have made the
recommendations had
previous acquaintance with
the patient the applicant
should state here why it is
not practicable to obtain a
recommendation from a
practitioner having such
acquaintance.
7. (5) .............................................................
................................................................................
................................................................................
................................................................................
Signed ........................
Date ........................
Record of Admission
(This is not part of the application, but is to be completed later at the hospital)
(6) Name of patient. ( a ) (6) ........................................... was admitted
to (7) ...................... in pursuance of this application
on ...................... .
OR
( b ) (6) .......................................... was already
in (7) ............................ on the date of this
application, and the application was received by me
on behalf of the manager on ........................ .
(7) Name of hospital.
Delete ( a ) or ( b )
Signed ........................
on behalf of the manager
Date ........................
14 g S.L.262.01 HOSPITAL ADMISSION FORMS
SEVENTH SCHEDULE
MENTAL HEALTH ACT
Medical Recommendation for Admission for Treatment
(Article 14)
ARTICLE 17(3) MENTAL HEALTH ACT
This medical recommendation shall not be given by any of the following
persons:
( a ) applicant;
( b ) a partner of the applicant or of a practitioner by whom another medical
recommendation is given for the purpose of the same application;
( c ) a person employed by the applicant or by any such practitioner as
aforesaid,
(1) Name and address
of medical practitioner.
1. I (1) ........................................................ of
................................................................................
being a registered medical practitioner recommend
that (2) ............... of ................................................
be admitted to a hospital for treatment in accordance
with Part III of the Mental Health Act.
(2) Name and address
of patient.
2. I last examined this patient on ...............
* Delete if not applicable. 3. *( a ) I was acquainted with the patient
previously to conducting that examination.
*( b ) I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
(3) Insert mental
illness, severe subnormality,
subnormality and/or
psychopathic disorder.
4. In my opinion this patient is suffering from
(3) .................................... of a nature or degree
which warrants his/her detention in a hospital for
medical treatment within the meaning of the Act.
This opinion is founded on the following grounds:
(4) Clinical description
of the patient’s mental
condition.
(4) ...................................................................
................................................................................
................................................................................
................................................................................
5.  I am of the opinion that it is necessary -
Delete (i) or (ii) unless
both apply.
(i) in the interests of this patient’s
health or safety,
(ii) for the protection of other persons,
(5) Reasons should
indicate whether other
methods of care or
treatment (e.g. outpatient
treatment) are available and
if so why they are not
appropriate and why
informal admission is not
suitable.
that this patient should be detained in a hospital and
my reasons for this option are: (5)
Signed ........................
Date ........................
HOSPITAL ADMISSION FORMS g S.L.262.01 15
( d ) a person who receives or has an interest in the receipt of any payments
made on account of the maintenance of the patient; or
( e ) the husband or wife or a relative by consanguinity or affinity up to the
second degree of the patient, or of any such person as aforesaid or of a
practitioner by whom another medical recommendation is given for the
purpose of the same application.
16 g S.L.262.01 HOSPITAL ADMISSION FORMS
EIGHTH SCHEDULE
MENTAL HEALTH ACT
Joint Medical Recommendation for Admission for Treatment
(Article 14)
(1) Names and
addresses of both medical
practitioners.
1. We (1) ........................................................
of ............................................................................
and ..........................................................................
of ............................................................................
being registered medical practitioners, recommend
that (2) ................. of ..............................................
be admitted to a hospital for treatment in accordance
with Part III of the Mental Health Act.
(2) Name and address
of patient.
(3) Name of first
practitioner.
2. I (3) ............................... last examined this
patient on ......................
* Delete if not applicable. * I was acquainted with the patient previously
to conducting that examination.
* I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
(4) Name of second
practitioner.
3. I (4) ............................... last examined this
patient on ...................... ......................
* Delete if not applicable. * I was acquainted with the patient previously
to conducting that examination.
IMPORTANT: Medical
practitioners must have
personally examined the
patient either together or at
an interval of not more than
3 days.
* I have been approved by the Minister
responsible for Public Health under article 17 of the
Act as having special experience in the diagnosis or
treatment of mental disorder.
(5) Names of both
practitioners.
(6) Insert mental illness
severe subnormality,
subnormality and/or
psychopathic disorder.
4. We (5) ................................................. and
........................... are of the opinion that this patient
is suffering from (6) ............................... of a nature
or degree which warrants his/her detention in a
hospital for medical treatment within the meaning of
the Act. This opinion is founded on the following
grounds:
(7) Clinical description
of the patient’s mental
condition.
5. We are of the opinion that it is necessary -
Delete (i) or (ii) unless
both apply.
(i) in the interests of this patient’s
health and safety,
(ii) for the protection of other persons,
HOSPITAL ADMISSION FORMS g S.L.262.01 17
ARTICLE 17(3) MENTAL HEALTH ACT
This medical recommendation shall not be given by any of the following
persons:
( a ) applicant;
( b ) a partner of the applicant or of a practitioner by whom another medical
recommendation is given for the purpose of the same application;
( c ) a person employed by the applicant or by any such practitioner as
aforesaid;
( d ) a person who receives or has an interest in the receipt of any payments
made on account of the maintenance of the patient; or
( e ) the husband or wife or a relative by consanguinity or affinity up to the
second degree of the patient, or of any such person as aforesaid or of a
practitioner by whom another medical recommendation is given for the
purpose of the same application.
(8) Reasons should
indicate whether other
methods of care or
treatment (e.g. outpatient
treatment) are available and
if so why they are not
appropriate and why
informal admission is not
suitable.
that he/she should be detained in hospital, and our
reasons for this opinion are: (8)
Signed ........................
Date ........................
Signed ........................
Date ........................
18 g S.L.262.01 HOSPITAL ADMISSION FORMS
NINTH SCHEDULE
MENTAL HEALTH ACT
Report on Hospital In-Patient
(Article 18)
(1) Name of hospital in
which the patient is.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name of
practitioner.
1. I (2) .................................... am the medical
practitioner in charge of the treatment of (3)
................................., who is an in-patient in this
hospital and not at present liable to be detained
under the Mental Health Act. I hereby report for the
purposes of article 18 of the Act, that it appears to
me that an application ought to be made for this
patient’s admission to hospital under Part III of the
Act for observation or for treatment.
(3) Name of patient.
Signed ........................
Date ........................
To be completed on behalf of the manager
This report was received by me on behalf of the
manager on ...........
Signed ........................
on behalf of the manager
HOSPITAL ADMISSION FORMS g S.L.262.01 19
TENTH SCHEDULE
MENTAL HEALTH ACT
Renewal of Authority for Detention in a Hospital
(Article 21(4))
(1) Name of hospital in
which the patient is liable to
be detained.
TO THE MANAGER OF (1) ................................
................................................................................
(2) Name of patient. 1. I examined (2) .................................. on
............................ and hereby report that I am of the
opinion that this patient is suffering from (3)
............................. and that it is necessary -
(3) Insert mental
illness, severe subnormality,
subnormality and/or
psychopathic disorder.
(i) fin the interests of the patient’s
health and safety,
(ii) for the protection of other persons,
(4) Date on which
authority for detention is
due to expire if not
renewed.
that the patient should continue to be liable to be
detained under the Mental Health Act, beyond (4)
..........................
2. The reasons why this patient cannot suitably
remain in hospital informally or be discharged from
hospital are:
Signed ........................
Responsible Medical Officer
Date ........................
(The following is not part of the renewal, but is to
be completed on behalf of the manager of the
hospital).
This report was received by me on behalf of the
manager on .......
Signed ........................
Date ...........................
This report has been considered by the manager/
persons authorised to act on behalf of the manager
who have decided to order/not to order that the
patient be discharged.
(5) Delete if the patient
is under 16 years of age or if
the manager orders the
patient’s discharge.
(5) The patient has been informed of the receipt
of this report.
Signed ........................
on behalf of the manager
Date ...........................
20 g S.L.262.01 HOSPITAL ADMISSION FORMS
ELEVENTH SCHEDULE
MENTAL HEALTH ACT
Report Barring Discharge by Nearest Relative
(Article 29)
(1)  Name of hospital in
which the patient is liable to
be detained.
TO THE MANAGER OF (1) ................................
................................................................................
I hereby report, for the purposes of article 29 of
the Mental Health Act, that I am of the opinion that
(2) ........................ if discharged, would be likely to
act in a manner dangerous to other persons or to
himself/herself.
(2) Name of patient.
Signed ........................
Responsible Medical Officer
Date ........................
To be completed on behalf of the manager.
(3) Time and date. This report was received by me on behalf of the
manager at ............................ (3) on .......................
Signed ........................
Date ...........................
The patient’s nearest relative, whose notice of
intention to order the patient’s discharge was
received at (3) ........................... on ........................
was informed of this report on ..........................
Signed ........................
on behalf of the manager
Date ...........................
