CHIEF FORENSIC PSYCHIATRIST APPROVED FORM 12C

CHIEF FORENSIC PSYCHIATRIST APPROVED FORM 12C
CANCELLATION OF
FORENSIC PATIENT
LEAVE
Mental Health Act 2013
THCI: (Patient Id):
Family Name: __________ Given Name:___________
DOB: _____/_____/_____ Gender: M ☐ F☐ TG/IT☐
Address: _________________________________________
Phone: ____________ Mob:
Sections 77 – 79 and 81 - 84
______________
AFFIX STICKER HERE
PART A: LEAVE CANCELLED
NOTICE TO THE PATIENT
CHIEF FORENSIC PSYCHIATRIST / DELEGATE / CONTROLLING AUTHORITY OF SMHU / TREATING MEDICAL
PRACTITIONER / APPROVED MEDICAL PRACTITIONER TO COMPLETE
Patient’s name: ____________________________________________________________________________________
Patient’s status: ☐ Subject to a restriction order OR ☐ Not subject to a restriction order
Type of leave: ☐ Clinical OR ☐ Personal
This form is to be used to
cancel leave that has been
granted to ANY forensic
patient, including a forensic
patient who is subject to a
restriction order.
A responsible authority, by notice
to the patient, may cancel leave
granted at any time if the
responsible authority believes that
its continuation would, or is likely
to, seriously endanger the
patient’s health or safety; or place
the safety of other persons at
serious risk.
The Chief Forensic Psychiatrist or
a delegate, the controlling
authority for the secure mental
health unit or delegate, the
treating medical practitioner, or
an approved medical practitioner
may be a responsible authority
for a forensic patient who is not
subject to a restriction order.
The Mental Health Tribunal and
Secretary for the Department of
Health and Human Services may
additionally be a responsible
authority for a forensic patient
who is subject to a restriction
order.
On the cancellation of a patient’s
leave, an MHO or police officer
may apprehend and return the
patient under escort to the
SMHU.
Date leave granted:
/
/
☐ Leave Pass Attached
Responsible authority’s name: ________________________________________________
Responsible authority’s status:
☐ Chief Forensic Psychiatrist (or a delegate)
☐ Controlling authority of the SMHU (or a delegate)
☐ Patient’s treating medical practitioner
☐ Approved medical practitioner
☐ Mental Health Tribunal
☐ Secretary, Department of Health and Human Services (or a delegate)
I believe that continuing the above named patient’s leave would, or is likely to:
☐ Seriously endanger the patient’s health or safety OR ☐ Place the safety of others at serious
risk.
I hereby cancel the patient’s leave.
Date and time leave cancelled: Date: ____/____/_____ Time: ____:____ (24 hr)
Is the person cancelling the leave completing this form?
☐ Yes – person to sign here: _____________________________________________
☐ No – members of nursing/medical staff to complete:
We confirm that the person named above has cancelled leave of absence for the patient
named above for the reasons noted above:
Dr/Nurse Name/Payroll/ID Number 1: _____________ Signature: ___________________
Dr/Nurse Name/Payroll/ID Number 1: _____________ Signature: ___________________
COPY TO: ☐ Patient ☐ Controlling authority ☐ Applicant for the leave, if not the patient ☐ The patient’s intended escort ☐ Tribunal ☐ If patient
is NOT subject to a TO – the Commissioner of Police and Secretary, Corrections ☐ If patient is a prisoner –Director, Corrections ☐ If patient is a
youth detainee –Secretary, Youth Justice ☐ If patient IS subject to a Treatment Order – the CCP ☐ CFP (if the CFP was not the person who cancelled
the leave) ☐ LOC ☐ If patient is a child or if there is consent - patient’s parent/support person/representative OTHER: ☐ Statement of Rights to the
patient ☐ Statement of Rights to the applicant, if not the patient ☐ Explanation to patient in language and form that patient can understand
CONTACT DETAILS:
MHT: Phone: (03) 6165 7491 Email: [email protected]
CFP/CCP: Phone: (03) 6166 0781 Fax: (03) 6230 7739 Email: [email protected]
Secretary, Corrections: Phone: (03) 6165 7527 Fax: (03) 6233 5031 Email: [email protected]
Director of Corrective Services:
Phone: (03) 6216 8183 / 6165 7371 Fax: (03) 6216 8000 Email: [email protected]
Secretary (Youth Justice): Phone: (03) 6362 2311 Fax: (03) 6362 2217 Email: [email protected]
Commissioner of Police (or delegate): Phone: (03) 6230 2434 Fax: (03) 6230 2414 Email: [email protected]
Version 4: 15 December 2014
Page 1 of 2
CHIEF FORENSIC PSYCHIATRIST APPROVED FORM 12C
CANCELLATION OF
FORENSIC PATIENT
LEAVE
Mental Health Act 2013
THCI: (Patient Id):
Family Name: __________ Given Name:___________
DOB: _____/_____/_____ Gender: M ☐ F☐ TG/IT☐
Address: _________________________________________
Phone: ____________ Mob:
Sections 81 - 84
______________
AFFIX STICKER HERE
PART B: RECORD OF ESCORT
ESCORT AND MEMBER OF TREATING TEAM TO COMPLETE
The custody and escort
provisions apply to the
patient’s escort pursuant to a
Form 12C request.
Patient’s name: __________________________________________________________
Date and time of request to take patient under escort:
In taking a person under
escort, a Mental Health
Officer (MHO) or Police
Officer may take possession
of and safeguard any
medication, physical aid or
other thing that the escort
reasonably believes is or may
be necessary to the patient’s
health, safety or welfare, or
which may be relevant to the
patient’s examination,
assessment, treatment or
care.
Date: ___/___/___ Time: ____:___ (24 hr)
An escort may, as
circumstances require,
transfer physical control of a
person to another MHO or
Police Officer.
________________________________________________________________________
Custody is not taken to have
been interrupted or
terminated because physical
control of the person has
been handed over from one
MHO or Police Officer to
another such officer.
COMMENCEMENT OF ESCORT
Status and identity of MHO/Police Officer taking patient under escort (tick the
appropriate box):
☐ MHO. Name/ID Card Number/Payroll Number: __________________________________
☐ Police Officer. Name and Badge Number:_______________________________________
Details of any medication, physical aid, prescription or other things taken possession of and
safeguarded:
________________________________________________________________________
________________________________________________________________________
Date and time person taken under escort:
Date:
/
/
Time: ___:__ (24 hr)
Escort’s signature: _____________________________________________________
HANDOVER (COMPLETE ONLY IF CUSTODY HAS BEEN HANDED OVER)
Status and identity of MHO/Police Officer accepting handover (tick the appropriate box):
☐ MHO. ID Card/Payroll Number: _____________________________________________
☐ Police Officer. Name and Badge Number:_______________________________________
Details of medication, physical aids, prescriptions or other things handed over OR reasons for
such items not being handed over/alternative action taken:
________________________________________________________________________
________________________________________________________________________
Date and time custody handed over:
Date:
/
/
Time: ___:__ (24 hr)
Signature of escort accepting custody: ____________________________________
RETURN TO SECURE MENTAL HEALTH UNIT
Date and time of patient’s return: Date:
/
/
Time: ___:__ (24 hr)
COPY TO: ☐ CFP ☐ LOC
CONTACT DETAILS: CFP:
Version 4: 15 December 2014
Phone: (03) 6166 0781 Fax: (03) 6230 7739
Email: [email protected]
Page 2 of 2