FORM V11
Rule-25 of Central Mental Authority 1990,The Mental Health Act
1987
Application for reception order
(By Medical officer in charge of a psychiatric hospital)
From
Dr-------------------------------
To
The Magistrate,
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Sir,
Sub: Reception order for
----------------------------son/daughter of
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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 involuntary patient
and is not willing to continue. He/she has the following symptoms & signs.
1.
2.
3.
He/She requires to be in the hospital for treatment / personal safety / other
protection.
Thanking you,
Yours sincerely
Place: Signature-------------------------------------------
Date:
Name-----------------------------------------------