Form

Nature of Form

Relevant sections

1

Application for Reception Order

5

2

Medical Practitioner's Certificate as to Mental State of Patient

6, 16, 17 or 29(1)

3

Medical Practitioner's Certificate as to desirability of Further Detention of Patient

15

4

Reception Order

9

5

Application by Police Officer for Reception Order

12

6

Urgent Application

17

7

Application for Reception Order

20

8

Order for Further Detention

21

9

Master's Order for Further Detention

27(1)(a)

10

Direction for Patient's Removal to an Institution

28

11

Superintendent's Annual Report on Patient

32(1)

12

Notification of Death or Escape of Detained Patient

32(3)

13

Medical Certificate that Patient no longer mentally disordered or defective

34

14

Application for Own Admission as Voluntary Patient

36(1)

15

Application for admission of person under 16 years as voluntary patient

36(2)

16

Medical Recommendation

36

17

Warrant for Removal of Patient from Botswana

52

REPUBLIC OF BOTSWANA

MENTAL DISORDERS ACT

(section 5)

To: The District Commissioner,

..................................................................

    (a)    Particulars of Applicant

Full names ...................................................................................

Age ................................ Sex .....................................................

Occupation ..................................................................................

Address .......................................................................................

    (b)    Particulars of person for whom reception order is sought

Full names ...................................................................................

Age ................................ Sex .....................................................

Occupation ..................................................................................

Nationality ...................................................................................

Address .......................................................................................

    (c)    I declare that I am the person described in paragraph (a) above and I hereby make application for a reception order under the Act, for the person described in paragraph (b)(hereinafter called the patient).

    (d)    I believe the patient is mentally disordered or defective.

    (e)    My reasons for so believing are as follows-

        ...........................................................................................................................

        ...........................................................................................................................

    (f)    The patient is my .................................................................................................

        ...........................................................................................................................
(state precise relationship)

    or    I am not a near relative of the patient and the reason why the application is made by me instead of by a near relative is

        ...........................................................................................................................

    (g)    I personally saw the patient on the ......... day of ..........................., 20..... (within 14 days immediately preceding the day on which this application is signed).

Signed ........................................................
Applicant

Date ..........................................................

REPUBLIC OF BOTSWANA

MENTAL DISORDERS ACT

(section 6, 16, 17 or 29(1))

    (a)    I, ............................................................................ (give full names) residing at...................................................................................................................... being a registered medical practitioner, hereby certify that at .................. (state hour) on the ........ day of ..........................., 20 ......, at ................................... I personally examined ...............................................................being a male/female approximately................................................................ years of age whose address is .................................................................................................

    (b)    As a result of the examination I am of the opinion that the patient belongs to Class I/Class II/Class III of mentally disordered or defective persons specified in section 3 of the Act.

    (c)    The following facts indicative of mental disorder or defect were observed by me during the abovementioned examination-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    (d)    The following facts indicative of mental disorder or defect have been observed by me on previous occasions (give approximate dates)-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    (e)    The following facts indicative of mental disorder or defect have been communicated to me (set out facts communicated by other persons with names and addresses of those persons)-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    (f)    In my opinion the factors which have caused the mental disorder or defect are ..........

        ...........................................................................................................................

        ...........................................................................................................................

    (g)    In my opinion the patient is not suicidal/homicidal/in any way dangerous to himself or others (strike out what is inapplicable).

    (h)    The following treatment has been received by the patient in respect of his/her mental condition-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    (i)    The bodily health and condition of the patient is as follows-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    (j)    Is any communicable disease present? Yes/No.

        If so, what? ..........................................................................................................

        ...........................................................................................................................

    (k)    Is any recent injury present? Yes/No.

        If so, what? ..........................................................................................................

        ...........................................................................................................................

    (l)    In my opinion the patient does/does not require skilled medical attention.

    (m)    (under section 17). In my opinion this is/is not a case of urgency in which the patient should be immediately removed to an institution/hospital/prison/cell.

    (n)    (under section 29(1)). In my opinion it is/is not desirable that the patient shall remain under private care for the following reasons-

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

        ...........................................................................................................................

    I certify that I am not prohibited by the Act from signing this certificate and that I am a duly registered medical practitioner.

...................................................................
Signature and qualifications
of Medical Practitioner

Date ...........................................................

Place .........................................................

REPUBLIC OF BOTSWANA

MENTAL DISORDERS ACT

(section 15)

    (a)    I, ............................................................................ (give full names) residing at .................................................... being a registered medical practitioner, and being the practitioner on whose certificate a reception order endorsed under section 10 of the Act, was granted on the ........... day ................................, 20 ............... by the District Commissioner, ....................................., in respect of the patient ........................................................................... being a male/female approximately ............................................... years of age whose address is........, hereby certify that at ................................ (state hour) on the .............................. day of ....................................., 20........................ at ......................................., I again personally examined the said patient.