Sections 67, 68, 69

Form 29

Electroconvulsive Therapy (ECT) Licensing of Premises Application

An occupier of a premises must not permit electroconvulsive therapy to be performed on the premises unless the premises is licensed. Refer to Approved Procedure 12A - Electroconvulsive Therapy (ECT) Licensing of Premises for further information.

Application details

☐ Application for a licence to perform Electroconvulsive Therapy on the following premises OR ☐ Application to renew licence to perform Electroconvulsive Therapy on the following premises

Premises details

Premises title and address where Electroconvulsive Therapy is to be (or is being) performed: Is this an Approved Treatment Facility under the Mental Health and Related Services Act? (NB: Approved Treatment Facilities are not required to have a separate licence to perform Electroconvulsive Therapy) ☐ Yes ☐ No

Occupier details

Full name of occupier of premises or holder of existing licence: Signature: Date: / /

Note: Copies of recommendations from the Chief Health Officer and other information regarding this application are to be attached.