Mental Health and Related Services Act 1998

Section 166

Form 51

Under section 166, an Authorised Psychiatric Practitioner (APP) may grant an involuntary patient a leave of absence from an Approved Treatment Facility (ATF) if they are not a prisoner. Refer to Approved Procedure 8 – Leave management for involuntary patients, for further information.

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
Currently admitted at:
Part A - Leave details (Clinician to complete this section. Leave is not to be taken until approved by an APP)
Leave starts at:	Time:	hours	Date:	/ /
Leave finishes at:	Time:	hours	Date:	/ /
If leave is for recurring periods during the time above:	Leave may be taken for minutes / hours times per day
Person’s contact details while on leave:
Leave conditions: (Clinician to select all appropriate conditions and provide additional information where required) ☐ Hospital staff must be advised when the person is leaving the ward. ☐ An agreed escort is to accompany the person whilst they are on leave ☐ The person must: ☐ Not use or consume illicit drugs and alcohol. ☐ Not drive a motor vehicle. ☐ Not supervise children. ☐ Not have access to or use of firearm. ☐ Other specified conditions include (please list):
Part B - Primary carer/accompanying adult agreement (Primary carer/accompanying adult to complete this section)
I am to be the primary carer/accompanying adult of the above person while they will be on leave. The treating team and I have talked about the following: The person has NOT been discharged and must return to the hospital at the agreed time. There are things that the person is not allowed to do while on leave. As much as I can, I must: keep the person within view; and remain close to them; and go wherever they go. If I need to, I can take the person back to the hospital at ANY TIME. I am to ring the hospital, if: We will be back late; and/or Our plans change, including where we go and what we do; and/or Anything else happens - for example if the person: does not agree to come back to hospital; or does not take their medicine; or says that they want to hurt themselves or others; or acts inappropriately in any way. I have also been given: The names of people who can help me if I need it and information on my rights and entitlements.
Full name of primary carer/accompanying adult: Signature:	Relationship to person: Contact details:	Date: / /
Part C- Approval of leave (APP to complete. Leave is not be taken until approval is complete below)
I confirm that a risk assessment^ has been undertaken: by (insert name): on (insert date): / / And that the primary carer/accompanying adult during the period of leave has been provided with: ☐ The names and contact details of the staff who can assist them. ☐ Information on their rights and entitlements with regard to the period of leave. Under the provisions of section 166 of the Mental Health and Related Services Act 1998, I approve the granting of leave to the abovementioned person for the purpose(s) of: (please select whichever is appropriate) ☐ A period of leave that is likely to benefit the health and wellbeing of the person; ☐ It contributes to the person’s individual discharge plan; ☐ It is for the person to undergo surgical or medical treatment; or ☐ Other reason (please specify): under the conditions outlined in Part A of this form.
Full name of approving authorised psychiatric practitioner:	Signature:	Date: / /
^The risk assessment to guide the approval of leave by the APP should include considerations that the person may suffer serious mental or physical deterioration; likelihood of harm to himself or herself or to someone else and the person’s capacity to comply with all conditions of the leave.
Part D - Cancellation of Leave (Clinician to complete, only if appropriate.)
I confirm that I have cancelled the leave of the abovementioned person for the following reason/s: (please select) ☐ The person is likely to suffer from serious mental or physical deterioration as a result of a change in the person's mental state. ☐ The person is likely to cause harm to himself or herself or to someone else. ☐ The person has failed to comply with a condition of the leave. I can also confirm that the following has been notified of this: (please select) ☐ The person ☐ The person’s primary carer ☐ The person’s representative ☐ The person’s adult guardian ☐ The person in charge (PIC) of the approved treatment facility (ATF) ☐ The clinical nurse manager or on call delegate
Full name of authorised psychiatric practitioner:	Signature:	Date: / /
Part E – Failure to return from leave (Clinician to complete, only if appropriate.) NB: Form 52 Absconded or missing person should also be completed at this time.
I confirm that the abovementioned person has failed to return from leave and is currently absent without approval. I also confirm that the following has been notified of this: (please select all applicable) ☐ The authorised psychiatric practitioner ☐ The person’s adult guardian ☐ The person’s representative ☐ The person’s primary carer ☐ The Tribunal ☐ MHAT Team ☐ NT Police
Full name of clinician:	Signature:	Date: / /

Form Requirements

☐ Placed on clinical file

☐ Copy provided to primary carer/accompanying adult

☐ Sent to Tribunal (where person is absent without approval only)