Mental Health and Related Services Act 1998

Form 51A

Refer to Approved Procedure 8A – Leave management for voluntary inpatients, for further information on the granting of leave for voluntary patients.

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 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 advice: (Clinician to select all appropriate statement and provide additional information where required) ☐ Hospital staff are to be advised when the person is leaving the ward. ☐ An agreed escort is to accompany the person whilst they are on leave. ☐ The person should: ☐ 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 advice or recommendations include (please list):
Part B - Voluntary patient agreement
I understand that: ☐ I am in an approved treatment facility voluntarily for treatment under the Mental Health and Related Services Act 1998. ☐ As a voluntary patient I can leave the facility (i.e. be discharged pursuant to section 29 of the Act) at any time. ☐ That whilst in the facility, I have agreed to work with the treating team and to follow the facility’s rules and routines including making appropriate arrangements for taking leave whilst I am a patient of the service. ☐ The Authorised Psychiatric Practitioner and I have entered an agreement for me to be able to leave the facility for a period of time. ☐ This does not mean that I have been formally discharged from the facility or from the voluntary treatment arrangement. ☐ The details of my leave that has been approved by the Authorised Psychiatric Practitioner are documented in Part A of this form. I agree that: ☐ I will return to hospital at the time agreed and will comply with the conditions of leave discussed and agreed to with my doctor.
Full name of person:	Signature:	Date: / /
Part C – 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 D - 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, where applicable, 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; I hereby approve the granting of leave to the abovementioned person 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 E - Cancellation of leave (To be completed by an authorised psychiatric practitioner or senior registered nurse on duty as 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 have been notified of this: (please select) ☐ The person ☐ The person’s primary carer ☐ The person’s representative ☐ The person’s adult guardian ☐ The Authorised Psychiatric Practitioner ☐ The Person in Charge of the Approved Treatment Facility ☐ The Clinical Nurse Manager or on call delegate
Full name of clinician:	☐ APP ☐ Senior RNOD	Signature:	Date: / /
Part F – Failure to return from leave (Clinician to complete only if appropriate) NB: Form 52 Absconded or missing person must also be completed, if the person is unable to be located and contacted
I confirm that the abovementioned person has not returned from leave. I can also confirm that the following have 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 ☐ MHAT Team ☐ NT Police
Full name of clinician:	Signature:	Date: / /

Form Requirements

☐ Placed on clinical file

☐ Copy provided to primary carer/accompanying adult