FORMS |
|
THE MENTAL HOSPITALS ACT |
1. |
Information of Unsoundness of Mind |
Saint Lucia |
District ............................................................... of ....................................... informs the undersigned magistrate that he or she has good cause to suspect and believe and does suspect and believe that ........................... of ................................ is a (pauper) person of unsound mind and a proper subject of confinement. |
............................................. |
Informant. |
Taken and sworn this .......................................................................... day of ........................... 20 ......., ..................................................... before me |
........................................ |
magistrate. |
|
The Mental Hospitals Act |
2. |
Medical Certificate |
I, .................................... Medical Officer of ........................... District and being in actual practice as a Physician, (or Surgeon, as the case may be) hereby certify that I on the .................. day of ................. 20 ......., at ................... in the ................ of ................... personally examined .................. of ...................... and I hereby certify that the said ........................... is a person of unsound mind and a proper subject of confinement, and I have formed this opinion on the following grounds, namely— |
1. Facts indicating insanity observed by myself (here state the facts). |
2. Other facts (if any) indicating insanity communicated by others (here state the facts and by whom communicated). |
3. I have made inquiries of all persons known to me who seem likely to be able to give information as to any facts of the previous history of the said ................... likely to be of service with reference to his or her medical treatment. The following statement contains all such facts known to me. |
Statement |
(If any particulars in this statement are not known, this to be stated.) |
Name of patient and Christian name at length. |
Sex and age. |
Married, single, or widowed. |
Condition of life and previous occupation (if any). |
The religious persuasion as far as known. |
Previous place of abode. |
Whether first attack, age (if known) on first attack. |
When and where previously under care and treatment. |
Duration of existing attack. Supposed cause. |
Whether subject to epilepsy. |
Whether suicidal. |
Whether dangerous to others. |
Name and Christian name and place of abode of nearest known relative of the patient and degree of relationship. |
(Add any other facts proper to be stated.) |
Dated this ................................. day of ......................, 20 ....... . |
........................................... |
Medical Officer, |
District |