Mental Health and Related Services Act 1998

Form 60

Details of person to which request relates

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
☐ Voluntary	/ /
Section	Expiry Date
☐ Involuntary	/ /
Section	Expiry Date
Details of person making request (Authorised Psychiatric Practitioner, Designated Mental Health Practitioner or Medical Officer)
Full name of person making request:	Phone number:	Signature:
Position: ☐ Paramedic ☐ Medical Officer ☐ Designated mental health practitioner ☐ Authorised psychiatric practitioner	Team:
Title of approved treatment agency or facility, health clinic or other health service (please state):
Level of urgency (as determined by the summary risk assessment component of this form): ☐ Urgent – Immediate Police response required ☐ Non Urgent
Incident address (and rendezvous point)
Address/location/possible destination:	Contact phone number:
Rendezvous point location (if applicable):
Contact details of person’s carer or next of kin
Given name:	Surname:	Relationship:
Address:	Phone (BH):	Phone (AH):
Nature of assistance required ☐ Section 34 (Form 9) Police Assistance following recommendation for a psychiatric examination NOTE: The primary responsibility for the person’s custody and safety rests with the health service/facility/agency of the clinician that has authorised the Form 9 (which may also include an authorisation for police to assist), Any action or assistance provided by police under this authority will be at the direction/guidance of the assessing clinician. The preferred approach is for police to assist rather than act independently of mental health clinicians unless there are clear risks to safety. ☐ Section 53 (Form 20) Control and take the person to an approved treatment facility following suspension of a Community Management Order. ☐ Section 37 (Form 8) Apprehend and convey person to an approved treatment facility for assessment pursuant to assessment warrant issued by the Tribunal (Magistrate). ☐ Section 83A (2) and (4) (Form 45) Apprehend a prisoner who is absent without leave from an approved treatment facility. ☐ Section 166A (Form 52) Locate, detain and return an involuntary patient absent without leave from an approved treatment facility. ☐ Section 166B (Form 52) Report ‘missing patient’ to police. ☐ Section 30 (Form 52) Request to locate and detain and return a voluntary patient being detained by a nurse or medical officer because their condition has deteriorated since admission and may fulfil the criteria for involuntary admission. ☐ Section 165 Request for police to assist to prevent a person harming themselves or another person; or to maintain the good order and security of an approved treatment facility or the approved treatment agency. ☐ Part IIA NT Criminal Code (Unfitness to plead and not guilty by reason of mental impairment) s43ZF ‘Emergency Power of Apprehension’. ☐ Letter of Agreement between NT Police and Department of Health (Disclosure of information pertaining to terrorism, radicalisation to violent extremism, fixated persons, grievance fuelled violence, lone actor activity or concerns where there is a threat or risk to an individual or members of the community).
Relevant information (please complete details where known and as time permits)
Description of person:
Description of the characteristics of the particular mental illness:
Details of last sighting, behaviour and presentation of person:
Behaviour to be expected of person in the circumstances (including impact on behaviour/propensity of verbal/physical aggression towards others and/or self-harm):
Warning signs indicating deterioration in the person’s mental health/triggers that may escalate the situation (if known):
Risk assessment summary (guided by comprehensive risk assessments documented in clinical notes)
Suicidal risk (including information about previous suicidal ideation or attempts to commit suicide and lethality of previous suicide attempts):
☐ Risk of harm to others	☐ Low	☐ Moderate	☐ High
☐ Risk of self harm	☐ Low	☐ Moderate	☐ High
Details of risk (Including prior history of self harm or violence):
History of possessing firearms, dangerous weapons or drugs (if known):
Other details which may be relevant (not detailed previously)
Psychiatric history	☐ Yes	☐ No	☐ Unknown
Drug and alcohol history	☐ Yes	☐ No	☐ Unknown
Forensic history	☐ Yes	☐ No	☐ Unknown
Medical conditions	☐ Yes	☐ No	☐ Unknown
Additional details:
Does the person have children/dependents (at site or elsewhere) and what are their needs? ☐ Yes ☐ No Further details:
Is mandatory reporting or Territory Families (TF) involvement required? ☐ Yes ☐ No Further details:
Is a trusted friend or carer present or able to be contacted? ☐ Yes ☐ No Further details:
Police contact person details
Full name of police contact:	Rank:	Registration no:
Station:	Job No:	Phone no:
Outcome of assistance request (including request for ambulance or police assistance with transport)
Pursuant to the provisions of the Mental Health and Related Services Act 1998, police located and/or attended the person who: ☐ was conveyed to ☐ remained within
Location:	at (time): hours on (date): / /
At this location the person was subsequently: ☐ examined ☐ not examined ☐ returned and was: ☐ accepted by ☐ not accepted by Name of service/facility:
Additional details ( i.e. any further assistance required to transfer the person to hospital or an appropriate location):
Police were released from providing further assistance in this matter:
at (time):	hours	on (date):	/ /
Full name of person who authorised the release of police:	Signature:	Date: / /

Form requirements

☐ Copy provided to NT Police

☐ Placed on clinical file