Given Name(s)

Family Name of Patient

Address of the Patient if living in the community

Phone Number

I am an involuntary patient a security patient a forensic patient

of

I wish to appeal against

my detention in an approved mental health service

proposed/transfer to

the refusal of the Chief Psychiatrist to grant me leave special leave

my community treatment order. I want to be discharged off the order

the conditions of my community treatment order. I want the conditions changed

my restricted community order. I want to be discharged off the order

The grounds of my appeal are:

Date

TO BE COMPLETED IF A PERSON LODGES AN APPEAL ON BEHALF OF A PATIENT

I have a genuine concern for the abovenamed patient and lodge the appeal against his her continued detention on his her behalf.

Given Name(s)

Family Name of person lodging appeal

Address of person lodging appeal

Relationship to Patient
eg Community visitor, spouse, friend etc

Date

*Please note that due to circumstances beyond our control there may be a delay in the receipt of your email. The Mental Health Review Board does not accept responsibility for delays in transmission of e-mail messages. You should confirm receipt of urgent messages by telephoning the Board. If you wish to communicate with us about a hearing scheduled to be heard within 2 working days, you should telephone us, not send an e-mail.