Mental Health (Forms) Regulations 2004

Victorian Legislation and Parliamentary Documents i Mental Health (Forms) Regulations 2004 S.R. No. 149/2004 TABLE OF PROVISIONS Regulation Page 1. Objective 1 2. Authorising provision 1 3. Commencement 1 4. Principal Regulations 1 5. Involuntary Patients 2 6. New regulation 6A inserted 3 6A. Involuntary treatment orders 3 7. Application forms for licenses 3 8. Schedule 1 substituted 3 SCHEDULE 1—Form of Request for a Person to Receive Involuntary Treatment 3 9. Schedule 2 substituted 5 SCHEDULE 2—Form of Recommendation for a Person to receive Involuntary Treatment 5 10. Schedule 3 substituted 7 SCHEDULE 3 7 Form 1—Particulars of Use of Restraint 7 Form 2—Particulars of Use of Sedation 10 11. Schedule 4 substituted 12 SCHEDULE 4—Form of Authority to Transport Involuntary Patient 12 12. Schedule 6 substituted 14 SCHEDULE 6—Involuntary Treatment Order 14 13. Schedule 21 substituted 16 SCHEDULE 21—Electroconvulsive Therapy Return 16 ═══════════════ ENDNOTES 17 -- 1 of 18 -- Victorian Legislation and Parliamentary Documents 1 STATUTORY RULES 2004 S.R. No. 149/2004 Mental Health Act 1986 Mental Health (Forms) Regulations 2004 The Governor in Council makes the following Regulations: Dated: 30 November 2004 Responsible Minister: BRONWYN PIKE Minister for Health DIANE CASEY Clerk of the Executive Council 1. Objective The objective of these Regulations is to amend the Mental Health Regulations 1998. 2. Authorising provision These Regulations are made under section 142 of the Mental Health Act 1986. 3. Commencement These Regulations come into operation on 6 December 2004. 4. Principal Regulations In these Regulations the Mental Health Regulations 19981 are called the Principal Regulations. -- 2 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 2 5. Involuntary Patients (1) For the heading to Part 2 of the Principal Regulations substitute— "PART 2—INVOLUNTARY PATIENTS". (2) Insert the following heading to regulation 5 of the Principal Regulations— "Initiation of involuntary treatment". (3) For regulation 5(1) of the Principal Regulations, substitute— "(1) For the purposes of section 9(1)(a) of the Act, a request to initiate involuntary treatment must be in the form of Schedule 1.". (4) In regulation 5(3) of the Principal Regulations for "9(7), 9(7A)," substitute "9B(4),". (5) In regulation 5(4) of the Principal Regulations, for "9(7A)(c) of the Act," substitute "9A(1)(c) of the Act,". (6) In regulations 5(5), (6) and (7) of the Principal Regulations, for "section 9(8) of the Act," substitute "section 7 of the Act,". (7) In regulation 5(6)(b) of the Principal Regulations, for "that the person be admitted to and detained in the approved mental health service" substitute "that the person receive involuntary treatment from an approved mental health service". r. 5 -- 3 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 3 6. New regulation 6A inserted After regulation 6 of the Principal Regulations, insert— "6A. Involuntary treatment orders For the purposes of sections 12 and 12AA of the Act, an involuntary treatment order must be in the form of Schedule 6.". 7. Application forms for licenses In regulation 11(1) of the Principal Regulations, for "For the purposes of section 77(2)(a) and (b)" substitute "For the purposes of section 77(2)(b)". 8. Schedule 1 substituted For Schedule 1 to the Principal Regulations substitute— "SCHEDULE 1 FORM OF REQUEST FOR A PERSON TO RECEIVE INVOLUNTARY TREATMENT Mental Health Act 1986 Section 9 Mental Health Regulations 1998 Regulation 5(1) Schedule 1 REQUEST FOR PERSON TO RECEIVE INVOLUNTARY TREATMENT FROM AN APPROVED MENTAL HEALTH SERVICE TO THE *ADMITTING REGISTERED MEDICAL PRACTITIONER/ MENTAL HEALTH PRACTITIONER Please make an involuntary treatment order for: GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person who should be made subject to an Involuntary Treatment Order of: address of person who should be made subject to an involuntary treatment order r. 6 -- 4 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 4 GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person making the request of: address of person making the request Signed: Date: / / AUTHORISATION (Optional) I authorise: GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of other person authorised by the person making the request of: address of other person authorised by the person making the request … To take the abovenamed person to an appropriate approved mental health service. OR … To arrange for a mental health practitioner to assess the person. (please cross ⌧ one option only.) Signed: Date: / / signature of person making the request * delete as necessary __________________". r. 8 -- 5 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 5 9. Schedule 2 substituted For Schedule 2 to the Principal Regulations substitute— "SCHEDULE 2 FORM OF RECOMMENDATION FOR A PERSON TO RECEIVE INVOLUNTARY TREATMENT Mental Health Act 1986 Section 9 Mental Health Regulations 1998 Regulation 5(2) Schedule 2 RECOMMENDATION FOR PERSON TO RECEIVE INVOLUNTARY TREATMENT FROM AN APPROVED MENTAL HEALTH SERVICE PART A TO THE *ADMITTING REGISTERED MEDICAL PRACTITIONER/ MENTAL HEALTH PRACTITIONER Please make an involuntary treatment order for: GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person who should be made subject to an involuntary treatment order of: address of person who should be made subject to an involuntary treatment order (1) I am a registered medical practitioner. (2) I personally examined the abovenamed person: on the day of 20 at *am/pm. (3) It is my opinion that all the following criteria in section 8(1) of the Mental Health Act 1986 apply to the person: (a) the person appears to be mentally ill (a person is mentally ill if he or she has a mental illness, being a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory); and (b) the person's mental illness requires immediate treatment and that treatment can be obtained by the person being subject to an involuntary treatment order; and r. 9 -- 6 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 6 (c) because of the person's mental illness, involuntary treatment of the person is necessary for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and (d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and (e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of his or her freedom of decision and action. (4) I do not consider the person to be mentally ill by reason only of any one or more of the exclusion criteria listed in section 8(2) of the Mental Health Act 1986. (5) I base my opinion on the following facts. Facts personally observed by me on examination to support this recommendation: Facts communicated to me by another person to support this recommendation: * delete as necessary PART B TO BE COMPLETED WHERE NO FACTS ARE PERSONALLY OBSERVED (6) As no facts were personally observed by me to support this recommendation, the following facts were communicated directly to me *in person/in writing/by telephone/by electronic communication by: Dr. GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of other registered medical practitioner of: address of other registered medical practitioner doctor's telephone number: who examined the person on the day of 20 (being a period not more than 28 days prior to today's date) Facts communicated to me by other examining registered medical practitioner: r. 9 -- 7 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 7 PART C SIGNATURE (7) I consider that an involuntary treatment order should be made for the abovenamed person. GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of recommending registered medical practitioner Signed: Date: / / signature of recommending registered medical practitioner Qualifications: Address: Telephone no: * delete as necessary __________________". 10. Schedule 3 substituted For Schedule 3 to the Principal Regulations substitute— 'SCHEDULE 3 FORM 1—PARTICULARS OF USE OF RESTRAINT Mental Health Act 1986 Section 9B Mental Health Regulations 1998 Regulation 5(3) Schedule 3 Form 1 RESTRAINT FOR THE PURPOSES OF SAFELY TRANSPORTING A PERSON TO AN APPROVED MENTAL HEALTH SERVICE GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person restrained for safe transport of: address of person restrained for the purposes of safe transport r. 10 -- 8 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 8 (1) I am a "prescribed person" within the meaning of section 7 of the Mental Health Act 1986—a "prescribed person" is a member of the police force, an ambulance officer or a: • Registered medical practitioner • Registered nurse • Registered psychologist • Social worker • Occupational therapist— —employed, appointed or engaged to provide care and treatment to persons with a mental disorder in an approved mental health service, a State child and adolescent psychiatry service, any premises licensed under section 75 of the Act, a hospital admitting or caring for persons with a mental disorder, a mental health service of a community health centre, a psychiatric outpatient clinic or a community mental health service. (2) The abovenamed person is: … subject to a request (Schedule 1) and recommendation (Schedule 2). OR … subject to a request (Schedule 1) and authority to transport (Schedule 4). OR … subject to an involuntary treatment order (Schedule 6) and is to be taken to an approved mental health service under section 12(6) or section 12AC(4)(b) of the Mental Health Act 1986. OR … a patient absent without leave from an approved mental health service. (Please cross ⌧ one option only.) (3) I applied the following restraint/s to the abovenamed person to enable her/him to be taken safely to an approved mental health service: (Specify the type of restraint applied and the reason, each time restraint is used.) (a) Restraint: Reason applied: Date: Time applied: *am/pm Time removed: *am/pm. (b) Restraint: Reason applied: Date: Time applied: *am/pm Time removed: *am/pm. r. 10 -- 9 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 9 (c) Restraint: Reason applied: Date: Time applied: *am/pm Time removed: *am/pm. GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of prescribed person employed by: * Victoria Police / Ambulance Service (MAS/RAV)/mental health service/ other (please specify) of: business address of prescribed person Signed: Designation: Date: / / * delete as necessary __________________ r. 10 -- 10 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 10 FORM 2—PARTICULARS OF USE OF SEDATION Mental Health Act 1986 Section 9B Mental Health Regulations 1998 Regulation 5(3) Schedule 3 Form 2 SEDATION FOR THE PURPOSES OF SAFELY TRANSPORTING A PERSON TO AN APPROVED MENTAL HEALTH SERVICE GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person sedated for safe transport of: address of person sedated for the purposes of safe transport (1) I am a "prescribed registered medical practitioner" within the meaning of section 7 of the Mental Health Act 1986. (2) The abovenamed person is: … subject to a request (Schedule 1) and recommendation (Schedule 2). OR … subject to an involuntary treatment order (Schedule 6) and is to be taken to an approved mental health service under section 12(6) or section 12AC(4)(b) of the Mental Health Act 1986. OR … a patient absent without leave from an approved mental health service. (Please cross ⌧ one option only.) (3) The person has refused or is unable to consent to sedation. I consider that it is necessary to sedate the person so that the person can be taken safely to an approved mental health service. The reasons for my decision are: (4) The following sedation is to be administered to the person: Drug: Dose: Route (IM, IV, Oral): Frequency: r. 10 -- 11 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 11 (5) … I administered the sedation myself at the following time/s: *am/pm OR … I direct the following "authorised person" to administer the sedation in the prescribed form: (Please cross ⌧ one option only.) GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of authorised person GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of prescribed registered medical practitioner of: address of prescribed registered medical practitioner Signed: Qualifications: Date: / / TO BE COMPLETED AS NECESSARY BY AUTHORISED PERSON (1) I am an "authorised person" within the meaning of section 7 of the Mental Health Act 1986—an "authorised person" is a registered medical practitioner or a registered nurse. (2) I administered the following sedation as prescribed by the abovenamed medical practitioner: Drug: Dose: Route (IM, IV, Oral): Time (1): *am/pm Time (2): *am/pm GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of authorised person of: address of authorised person Signed: Qualifications: Date: / / * delete as necessary __________________'. r. 10 -- 12 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 12 11. Schedule 4 substituted For Schedule 4 to the Principal Regulations substitute— 'SCHEDULE 4 FORM OF AUTHORITY TO TRANSPORT INVOLUNTARY PATIENT Mental Health Act 1986 Section 9A Mental Health Regulations 1998 Regulation 5(4) Schedule 4 AUTHORITY TO TRANSPORT WITHOUT RECOMMENDATION TO THE ADMITTING REGISTERED MEDICAL PRACTITIONER Please examine: GIVEN NAME/S NAME (BLOCK LETTERS) of person of: address of person for the purpose of making a recommendation under section 9 of the Mental Health Act 1986. (1) I am a "mental health practitioner" within the meaning of section 7 of the Mental Health Act 1986. (2) I have observed a completed request relating to the abovenamed person. (3) A recommendation has not been completed because a registered medical practitioner was not available within a reasonable period to consider making a recommendation, despite all reasonable steps having been taken to secure the attendance of one. (4) It is my opinion that all the following criteria in section 8(1) of the Mental Health Act 1986 apply to the person: (a) the person appears to be mentally ill (a person is mentally ill if he or she has a mental illness, being a medical condition that is characterised by a significant disturbance of thought, mood, perception or memory); and (b) the person's mental illness requires immediate treatment and that treatment can be obtained by the person being subject to an involuntary treatment order; and r. 11 -- 13 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 13 (c) because of the person's mental illness, involuntary treatment of the person is necessary for his or her health or safety (whether to prevent a deterioration in the person's physical or mental condition or otherwise) or for the protection of members of the public; and (d) the person has refused or is unable to consent to the necessary treatment for the mental illness; and (e) the person cannot receive adequate treatment for the mental illness in a manner less restrictive of his or her freedom of decision and action. (5) I do not consider the person to be mentally ill by reason only of any one or more of the exclusion criteria listed in section 8(2) of the Mental Health Act 1986. (6) I base my opinion on the following facts personally observed by me on examination: (7) I consider that the person should be taken to an approved mental health service for examination by a registered medical practitioner for the purpose of making a recommendation under section 9 of the Mental Health Act 1986. GIVEN NAME/S NAME (BLOCK LETTERS) of mental health practitioner Signed: Date: / / Time: *am/pm Employed by: Designation: approved mental health service * delete as necessary __________________'. r. 11 -- 14 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 14 12. Schedule 6 substituted For Schedule 6 to the Principal Regulations, substitute— "SCHEDULE 6 INVOLUNTARY TREATMENT ORDER Mental Health Act 1986 Sections 12 and 12AA Mental Health Regulations 1998 Regulation 6A Schedule 6 INVOLUNTARY TREATMENT ORDER GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of person subject to Involuntary Treatment Order of: address of person subject to Involuntary Treatment Order To be completed by registered medical practitioner/mental health practitioner (1) … I am a registered medical practitioner employed by the approved mental health service. The abovenamed person has been taken to the approved mental health service. OR … I am a mental health practitioner within the meaning of section 7 of the Mental Health Act 1986. I have been requested to assess the abovenamed person. (please cross ⌧ one option only.) (2) I have sighted a completed request and recommendation relating to the person. (3) I hereby make an involuntary treatment order for the person on: the day of 20 at *am/pm. r. 12 -- 15 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 15 (4) The approved mental health service is: name of approved mental health service GIVEN NAME/S FAMILY NAME (BLOCK LETTERS) of *registered medical practitioner/mental health practitioner Signed: Designation: Address: Telephone no: * delete as necessary __________________". r. 12 -- 16 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 16 13. Schedule 21 substituted For Schedule 21 to the Principal Regulations substitute— "SCHEDULE 21 ELECTROCONVULSIVE THERAPY RETURN Mental Health Act 1986 TO THE CHIEF PSYCHIATRIST SCHEDULE 21 Section 80 Mental Health Regulations 1998 Regulation 13 ELECTROCONVULSIVE THERAPY RETURN From: Date: / / *approved mental health service / licensed premises Referring service (if applicable): .................................................. 1. Licensed premises/approved mental health services must submit a return every month—including a 'nil return' when no electroconvulsive therapy is performed in a given month. 2. Start a new page for each day. A page records electroconvulsive therapy performed on one day only. 3. Complete separate pages for patients from other 'referring services'. One page for each referring service. 4. Individual pages should be compiled to form the monthly return to the Chief Psychiatrist. 5. Information should be recorded using the code letter in brackets where applicable. Name of doctor administering ECT: ............................................ Name of anaesthetist: ................................................................... Mental Health Statewide Patient Number or Private Hospital UR Number Sex (M) or (F) Date of birth Country of birth Program type (A)Adult (G)Aged (K)CAMHS (S)Specialist (P)Private Legal status (I)nvoluntary (H)ospital Order (S)ecurity (F)orensic (N)o Status or Informal Treatment type (B)ilateral (U)nilateral (BF)Bilateral Bifrontal (BT)Bilateral Bitemporal Treatment phase (A)cute (C)ontinuation (M)aintenance Status (I)npatient (O)utpatient Consent type (P) Patient (A) Authorised Psychiatrist (PA) Patient & Authorised Psychiatrist Principal diagnosis to be treated by ECT (Use ICD Code No) I submit this return of electroconvulsive therapy performed at these premises as part of the monthly return to the Chief Psychiatrist. ......................................................................................................... Given Names Family Name (BLOCK LETTERS) of person completing this return Signed: ....................................... Designation: .............................. ..................................................................................................... Given Names Family Name (BLOCK LETTERS) of *delegated/authorised psychiatrist/ECT Director/Occupier of licensed premises Signed: ..................... Designation: ......................... Date: ......... *delete as necessary __________________". ═══════════════ r. 13 -- 17 of 18 -- Victorian Legislation and Parliamentary Documents S.R. No. 149/2004 Mental Health (Forms) Regulations 2004 17 ENDNOTES 1 Reg. 4: S.R. No. 120/1998 as amended by S.R. Nos 45/2001 and 111/2003. Endnotes -- 18 of 18 --