Form A3 Regulation 4(1)(b)(i)	Mental Health Act 1983
Section 2 – joint medical recommendation for admission for assessment

We, registered medical practitioners, recommend that (PRINT full name and address of patient)

be admitted to a hospital for assessment in accordance with Part 2 of the Mental Health Act 1983. I (PRINT full name and address of first practitioner)

last examined this patient on

/	/

(date)

I had previous acquaintance with the patient before I conducted that examination.
I am approved under section 12 of the Act as having special experience in the diagnosis or treatment of mental disorder.
(* Delete if not applicable)
I (PRINT full name and address of second practitioner)

last examined this patient on

/	/

(date)

I had previous acquaintance with the patient before I conducted that examination.
I am approved under section 12 of the Act as having special experience in the diagnosis or treatment of mental disorder.
(* Delete if not applicable)
In our opinion,
this patient is suffering from mental disorder of a nature or degree which warrants the detention of the patient in hospital for assessment (or for assessment followed by medical treatment) for at least a limited period,
AND
ought to be so detained
in the interests of the patient’s own health
in the interests of the patient’s own safety
with a view to the protection of other persons.
(Delete the indents not applicable)

continue overleaf

Our reasons for these opinions are:
(Your reasons should cover both (a) and (b) above. As part of them: describe the patient’s symptoms and behaviour and explain how those symptoms and behaviour lead you to your opinion; explain why the patient ought to be admitted to hospital and why informal admission is not appropriate.)

(If you need to continue on a separate sheet please indicate here ( ) and attach that sheet to this form)

Signed	Date

/	/

Signed	Date

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NOTE: AT LEAST ONE OF THE PRACTITIONERS SIGNING THIS FORM MUST BE APPROVED UNDER SECTION 12 OF THE ACT.