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Be it enacted by Parliament in the Thirty-eighth Year of the Republic of India as follows:
Form I - Application for grant of licence for establishment / maintenance of psychiatric hospital / nursing home To The................................Officer, Government................................. ........................................................ ? Dear Sir/Madam,? I/We intend to establish/maintain a Psychiatric Hospital/Psychiatric Nursing Home in respect of which I am/we are holding a valid licence for the establishment/maintenance of such hospital/nursing home. The details of the hospital/nursing home are given below: 1. Name of Applicant?
b. Number of beds? Facilities provided:? a. Out-patient? Staff Pattern:? a. Number of Doctors? I am sending herewith a bank draft for Rs............................. Drawn in favour of ............................................... as licence fee. I hereby undertake to abide by the rules and regulations of the Mental Health Authority. I request you to consider my application and grant the licence for establishment/maintenance of Psychiatric Hospital/nursing home. Yours faithfully, Signature............................... Name ...................................... Date ........................................
Form II - Application for establishment of psychiatric hospital / nursing home under Sub Section (2) of Sec. 7 To The................................................................... Government....................................................? Dear Sir/Madam, I/We intend to establish a Psychiatric Nursing Home/Psychiatric Hospital at ..................... (mention the place). I am herewith giving you the details. 1. Name of the Applicant?
b. Number of beds.? Facilities provided: i. Out-patient? I am herewith sending a bank draft for Rs ............................... drawn in favour of .................................. as licence fee. I hereby undertake to abide by the rules and regulations of the Mental Health Authority. I request you to consider my application and grant licence. Yours faithfully, Signature............................... Date ........................................
Form III - Grant of licence for establishment of psychiatric hospital/nursing home I ..........................being the licensing authority under the Mental Health Act, 1987, after considering the application received under Sec. 7 and satisfying the requirements provided for in Sec. 8 and the other provisions of the Mental Health Act, 1987 (Central Act 14 of 1987) and the rules made thereunder, hereby grant the licence for establishment/maintenance of a psychiatric hospital or nursing home in favour of ............................... ( the applicant). 2. The licence shall be valid for the period commencing from ........................ and ending with ................... The licence shall be subject to the conditions laid down in the Mental Health Act, 1987 (14 of 1987) and the rules made thereunder. Licensing Authority? Place............................. Date...............................
Form IV - Application for renewal of licence SEAL Dr............................................................ ................................................................. ................................................................. ? District Health Officer ................................................................. ................................................................. Sir,? Subject : Renewal of Licence No...............................dated..................... I request you to kindly renew my licence No........................ dated the ...................... for the next 5 years. I am providing the facilities as prescribed by the Act and the rules framed thereunder. I have herewith attached a demand draft for Rs. 100 only. Thanking you.? Yours faithfully? Signature............................... Name ......................................
Form V - Application for appeal To,? The Appellate Authority Sir,? I, Dr....................................................... of ............................................................ had applied for licence for establishing a Pspychiatric Nursing Home/Hospital at ................................. (copy of the earlier application to be attached). My application was rejected by the licensing authority as per his/her letter No. ................................ Dated .......................................................................... with the following: 1.? 2.? 3.? (copy enclosed) The above reason(s) appear to be not valid. I request you to reconsider my application. My justifications are: 1.? 2.? 3.? I am willing to appear before you for a personal hearing, if necessary. I am herewith enclosing a draft for Rs. 500. Thanking you. Yours faithfully, Signature............................... Name ...................................... Place .......................................
Form VI - Proforma of case record Name of the hospital/nursing home ................................ Patient's name ........................... Age .................... Sex ................. Date of admission ........................... date of discharge ......................... Mode of admission ........................... Voluntary. Reception order.? Complaints (report from relative/other sources) Clinical State and side effect Treatment? Date? Final diagnosis
Form VII - Application for reception order (by medical officer-in charge of a psychiatric hospital) From? Dr............................................................ ................................................................. ................................................................. ? To? *The Magistrate ................................................................. ................................................................. Sir,? Subj: Reception order for .......................... son/daughter of ..................... I, Dr .......................... maintain psychiatric hospital/nursing home at ............................. Under licence No ..................... dated ................... I request you to issue reception order in respect of Sh/Smt...................... son/daughter of .................... who is being treated at my hospital as a voluntary patient and is not willing to continue. He/she has the following symptoms and/or signs. 1.? 2.? 3.? 4.? 5.? He/She requires to be in the hospital for treatment/personal safety/others Protection.? Thanking you.? Yours sincerely? Signature.................................. Place...................................
Form VIII - Application for reception order (by relative or other) To ................................................................. ................................................................. ................................................................. ? Subject: Admission of ..................................... son/daugher of ............................. into psychiatry hospital/nursing home as in-patient. I .......................................... son/daughter of ........................................... residing at ................................................................... ........................................................................... request you kindly arrange for admission in respect of Sh/Smt ..................................................... Aged .............. Years .......................... son/daugher of ........................................ An in-patient To ................................. (name of the hospital) or any other hospital/nursing home. He/She has the following suggestive of mental illness. 1.? 2.? 3.? 4.? 5.? I, who is ...................................... (relationship) of Sh./Smt ....................................... have an income ................. Rs ............................ and agree to pay the charges of treatment, if any of the institution. I state that, I have/have not made any such regard to the mental condition of ................................... as required. I herewith enclose the two medical certificates needed for the purpose. Witnesses: Yours faithfully, Name................................................
Form IX - Application for leave of absence (By relative or others) To Dr............................................................ ................................................................. ................................................................. Sir, Subject: Request for leave of absence of Sh/Smt ............................................. aged ................ years Admitted on .......................................... to your Institute. I request that Sh/Smt ......................... son/daughter of ......................... Be delivered to my care and custody on leave of absence. I hereby bind myself that on the said Sh/Smt ........................................... being made over to my care and custody, I will have him here/properly taken care of and prevent from doing injury to himself or to others. Yours faithfully,? Signature.................................. Name..........................................
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