Mental Health and Related Services Act 1998

Sections 166A and 166B

Form 52

Refer to Approved Procedure 166A – Inpatients Absent without (Approved) Leave or Missing for further information on the management of absconded or missing voluntary and involuntary inpatients. Refer to Approved Procedure 4 – Community Management for further information of the management of missing clients on a Community Management Order.

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
Approved Treatment Facility/Agency name:
Part A - Person details and risk assessment
The abovementioned person is currently: ☐ Admitted as a voluntary patient at the abovementioned facility ☐ Admitted as an involuntary patient on the grounds of mental illness/mental disturbance at the abovementioned facility ☐ An involuntary client on a Community Management Order with the abovementioned agency And has: ☐ Failed to return to the facility in line with the conditions of their approved leave ☐ Failed to return to the facility following cancellation/expiry of their approved leave ☐ Been found to be absent from the facility without approved leave ☐ Been found to be absent from the facility while being detained by a nurse or medical officer pending further assessment ☐ Been found to be missing from the facility ☐ Been found to be missing whilst on a Community Management Order
This was noted at:
Time:	hours	Date:	/ /
Possible locations and/or destinations of the person include:
Risk Assessment: The risk of harm to others in relation to the above mentioned person is low/medium/high. The risk to the person themselves is low/medium/high. The person’s vulnerability is considered to be low/medium/high. Details of the person’s risk status are as follows:
Full name of Authorised Psychiatric Practitioner (or delegate):	Signature:	Date: / /
Part B - Apprehension of involuntary patients by police
Pursuant to section 166A (2) of the Mental Health and Related Services Act I request that a police officer apprehend the above mentioned person and return them to the stipulated facility/agency. Under the Act, police may enter a private premises or any other private place where they reasonably believe that the person may be found and use reasonable force and assistance as necessary. I confirm that a Form 60 - Police Assistance Request has also been completed. ☐ Yes ☐ No
Name of Facility/Agency:
Full name of Authorised Psychiatric Practitioner (or delegate):	Signature:	Date: / /
Part C - Return acknowledgement and release of police from providing assistance
Pursuant to section 166(a) of the Mental Health and Related Services Act1998, the person was apprehended by the following and returned to the facility/agency stipulated below. I confirm that where appropriate, the Form 60 - Police Assistance Request has been updated to reflect when police were released from assisting in this matter. ☐ Yes ☐ No
Name of Facility/Agency:
Time of return:	hours	Date of return:	/ /
Full name of Authorised Psychiatric Practitioner (or delegate):	Signature:	Date: / /
Part D - Missing person notification to police NB: If a voluntary or involuntary inpatient or person on a community management order is missing, the person-in-charge of the approved treatment facility or agency (or delegate) must make a report to police as soon as possible.
Is the person considered to be a missing person? ☐ Yes ☐ No
If yes Please complete Form 60 - Police Assistance Request, ensuring that the most recent risk assessment guides you in selecting an appropriate urgency status. I confirm that a Form 60 Police Assistance Request has been completed. ☐ Yes ☐ No
If no Please outline the reasons why:
Full name of Person in Charge (or delegate):	Signature:	Date: / /

Form Requirements

☐ Copy provided to NT Police with a completed Form 60

☐ Placed on clinical file