Section 66

Form 27

Electroconvulsive Therapy (ECT) Authorisation or Notification

It is an offence to perform electroconvulsive therapy (ECT) on another person unless the treatment is in accordance with section 66 of the Act. Refer to Approved Procedure 12 - Electroconvulsive Therapy (ECT) for further information.
Electroconvulsive Therapy (ECT) details
Full name of person requiring Electroconvulsive Therapy (ECT): Also known as: Date of Birth: / /	Sex: ☐ Male ☐ Female ☐ Non-binary ☐ Not specified Type of patient: ☐ Voluntary ☐ Involuntary HRN:
Details of most recent examination: Place: Time: Date: / /
Has ECT already been undertaken? ☐ No - consent is now being sought from the persons adult guardian or nominated decision maker prior to undertaking ECT ☐ No - authorisation is now being sought from the Tribunal prior to undertaking ECT ☐ Yes - ECT was performed on / / because it was immediately necessary to: ☐ save the person’s life ☐ prevent the person suffering serious mental or physical deterioration ☐ relieve severe distress
If yes: Provide details on the person’s response to ECT if already performed:
Provide details of any significant side effects of ECT on the person if already performed:
Is authorisation now also being sought from the Tribunal for further ECT treatment for the person? ☐ No ☐ Yes
Details of the person’s clinical condition:
Details of the person’s history of treatment:
Details of other appropriate treatment/s available to the person:
Reasons why ECT is a reasonable and proper treatment to be administered for this patient:
Risks associated with the person having the treatment and risks associated with the person not having the treatment:
Without ECT, the person is likely to suffer serious mental or physical deterioration? ☐ Yes ☐ No Please provide details:
Steps taken to try to gain consent: (including supports provided such as use of interpreters, patient advocates, peer support workers, Community Visitor Program or other advocates)
What is the person’s objection and/or why are they are not able to provide consent?
Summary of evidence to support opinion that the person is unable to provide informed consent to ECT:
Have all reasonable efforts have been made to consult the person’s primary carer? ☐ Yes ☐ No If no, why not?
Does the person have an Advance Personal Plan or Enduring Power of Attorney in place that relates to this application/notification? ☐ Yes ☐ No ☐ Unknown Please provide details:
Full name of first Authorised Psychiatric Practitioner: Signature: Name of Approved Treatment Facility or Agency: Date: / /	Full name of second Authorised Psychiatric Practitioner: Signature: Name of Approved Treatment Facility or Agency: Date: / /
Consent by Adult Guardian or decision maker* (if applicable) Note – This form is not required to be submitted to the Tribunal, if adult guardian or decision maker consent is obtained prior to ECT. ☐ This section is not applicable for this person; or ☐ I give consent ☐ I do not give consent to treatments (up to 12 treatments) in the course of ECT, which may take up to weeks to complete (up to a maximum of 26 weeks) on this person.
Full name of Adult Guardian/decision maker:	Signature:	Date: / /
Acknowledgement and/or Authorisation by the Tribunal (select appropriate statement/s) ☐ I acknowledge that ECT has already been performed on this person because it was immediately necessary to: save the person’s life; or prevent the person suffering serious mental or physical deterioration; or relieve severe distress. AND / OR ☐ I authorise ☐ I do not authorise treatments (up to 12 treatments) in the course of ECT, which may take up to weeks to complete (up to a maximum of 26 weeks) on this person (who may or may not have already received ECT treatment prior to authorisation).
Full name of presiding member of the Tribunal:	Signature:	Date: / /

Form Requirements

☐ Placed on clinical file

☐ Sent to adult guardian (if applicable) | Date: / /

☐ Sent to decision maker (if applicable) | Date: / /

☐ Sent to Tribunal (if applicable) | Date: / /