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Form 3 - Mhc Application By A Member Of The Garda Sochana For A Recommendation For Involuntary 2001

Revised December 2011

APPLICATION

(TO A REGISTERED MEDICAL PRACTITIONER)

FORM 3

BY A MEMBER OF THE GARDA SÍOCHÁNA

MENTAL HEALTH

FOR A RECOMMENDATION FOR INVOLUNTARY

ACT 2001

(as amended)

ADMISSION OF AN ADULT

(TO AN APPROVED CENTRE )

SECTION 9 OR

SECTION 12

PAGE 1 OF 2

PAGE 1 OF 3

BLOCK CAPITALS

(Before completing this form please read the notes overleaf)

. This application is made

Section 9

Section 12

pursuant to:

. Full Name and Home

Address of PERSON

to be admitted to an

Approved Centre

. Date of Birth OR Age

(if Date of Birth not known)

Age:

Gender

. APPLICANT’S Full Name

First Name:

Surname:

. Telephone number

I hereby apply for a recommendation for the involuntary admission of the above named PERSON to

. Name and Address of

Approved Centre

I am applying for a recommendation for the involuntary admission of the above named person because

STATE:

. Reason for making

an application

. Any connection of

applicant with person

. Circumstances in which the

application is made

I am a member of the Garda Síochána based at

. Name and Address of

Garda Station

A person shall not make an application unless he or she has observed the person who is the

subject of the application not more than 48 hours before the date of the making of the application.

I last observed the person on

Time:

. Date:

(24 hour clock e.g. 2.41p.m. is written as 14.41)

If any previous application was refused, state if known

. Name of doctor who

refused application

. Date of refusal

. Circumstances pertaining

to the refusal

• It is an offence not to disclose all information that you are aware of that relates to any previous

applications for involuntary admission and their refusal.

• To the best of my knowledge and belief I am not disqualified from making this application for reasons

set out in Section 9(2) of the Mental Health Act 2001 (as amended). (Section 9(2) is replicated in the

notes overleaf).

Signed:

Garda Number:

Date:

Time:

(24 hour clock e.g. 2.41p.m. is written as 14.41)

For use only in accordance with the Mental Health Act 2001 as amended). Penalties apply for giving false or misleading information.

Form 3 - Mhc Application By A Member Of The Garda Sochana For A Recommendation For Involuntary 2001

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