Mental Health and Related Services Act 1998

Section 62

Form 22

A person who is being assessed or receiving treatment under the Mental Health and Related Services Act 1998 must not be kept in seclusion unless it is in accordance with section 62 of the Act. Refer to Approved Procedure 11 - Seclusion for further information.
NOTE: If the person has an adult guardian/decision maker/nominated family member/(primary) carer they are to be notified as soon as practicable after the seclusion.

Complete patient details or affix patient label in box below:
Full name of person:
Also known as
Date of birth:	/ /
HRN:
Sex:	☐ Male ☐ Female ☐ Non-binary ☐ Not specified
Name of Approved Treatment Facility:
Part A - Authorisation details NB: Where a senior registered nurse on duty has authorised seclusion in an emergency, an authorised psychiatric practitioner must be notified within one hour to review the authorisation (Part B.) PLEASE NOTE: Acknowledgment of seclusion initiated by non ATF staff is to be recorded in Part C.
Under the provisions of section 62 of the Mental Health and Related Services Act 1998, at (insert time): on (insert date): / / . I authorised for the person whose details appear above be placed into seclusion at the following location (insert location): for the following duration:
All reasonable and less restrictive options had been tried or considered and found to be unsuitable and the person was secluded for the following reason (select all appropriate): ☐ For the purpose of medical treatment of the person ☐ To prevent the person from causing injury to themselves or any other person ☐ To prevent the person from persistently destroying property ☐ To prevent the person from absconding from the facility Were there any variations in the required interval at which the person received a medical examination? ☐ Yes ☐ No If yes, state the reasons for the variation/s:
Full name of authorising person:	☐ authorised psychiatric practitioner ☐ senior registered nurse on duty	Signature:
Time:	hours	Date:	/ /
Part B - Review by authorised psychiatric practitioner (where initial order was made by a senior registered nurse on duty in an emergency) I confirm that I was notified by the senior registered nurse on duty within one hour of the seclusion being authorised ☐ Yes ☐ No If no, please provide additional details (where appropriate):
The person whose details appear above was still subject to a seclusion order when I attended them. I have examined the person, and (select appropriate): ☐ I am satisfied that the use of seclusion is necessary and all reasonable and less restrictive options have been tried or considered and found to be unsuitable. As such, I (select appropriate): ☐ Authorise the continuation of seclusion as per the aforementioned conditions. ☐ Make the following changes to the seclusion order:
OR ☐ I am not satisfied that the use of seclusion is necessary and direct the person be released from seclusion.
Full name of authorised psychiatric practitioner:	Signature:
Time:	hours	Date:	/ /
Part C - Acknowledgment of use of seclusion by non-clinician I acknowledge that the person whose details appear above has been placed in seclusion by: (select applicable) ☐ Corrections Officer(s) under the provisions of the Correctional Services Act 2014 ☐ Police Officer(s) under the provisions of the Police Administration Act 1978 ☐ Territory Families staff under the provisions of the Youth Justice Act 2005 This seclusion has therefore not been initiated under the provisions of section 61 of the Mental Health and Related Services Act 1998, however it will be recorded in the seclusion register. Full name of authorising person: ☐ authorised psychiatric practitioner ☐ senior registered nurse on duty Signature: Time: hours Date: / / Form Requirements ☐ Copy placed on seclusion register file ☐ Placed on clinical file