This legislation has been repealed.
(Sections 97, 98)
Mental Health Act 1990
|(name in full--use block letters)|
(state name of prison where examination took place)
separately from any other medical practitioner, I personally examined
(name of prisoner in full)
and I am of the opinion that *he/she is *mentally ill/suffering from a mental condition for which treatment is available in a hospital.
I have formed this opinion on the following grounds:
(1) Facts indicating *mental illness/mental condition observed by myself.
(2) Other relevant information (if any) communicated to me by others (state name and address of each informant).
Made and signed thisday of 19
*Delete whichever does not apply.