892
THE NEW ZEALAND GAZETTE.
[No. 19

1. I believe that the said person is mentally defective,
   upon the grounds following: [Set out in full the reasons
   for the applicant’s belief].
2. I am [Insert degree of relationship, if any, or words
   “not related”] to the said person, and this application is
   made by me [because I am the nearest relative; or if ap-
   plicant is not a relative or nearest relative, state why ap-
   plication is made by the applicant instead of by a relative
   or a nearer relative, the degrees of relationship being de-
   termined in the following order—(1) Husband or wife,
   (2) father or mother, (3) son or daughter, (4) brother or
   sister, (5) grandfather, grandmother, grandson, or grand-
   daughter, (6) any other relative], [or in pursuance of sec-
   tion 16 [or section 39 (7)] of the above-mentioned Act].
3. I have seen the said person within three days from
   the date of this application—namely, on the day of
   , 191 .
   *Dated at , the day of , 191 .
   [Ordinary signature of applicant.]

• Every application shall be presented to the Magistrate on the
  day it is signed, or within seven days following that date.—
  Section 4 (4).

FURTHER PARTICULARS TO BE SUPPLIED BY APPLICANT AS TO
PERSON IN RESPECT OF WHOM APPLICATION IS MADE.

Age: . Sex: .
Whether single, married, widowed, or divorced: .
Condition of life, and occupation: .
Religious persuasion: .
Country of birth: .
If not born in New Zealand, date of arrival: .
Nationality of parents: .
Whether first attack: .
If not, age at first attack: .
Number of former attacks (if any): .
Duration of present attack: .
Place of abode at commencement of present attack: .
When and where under oversight, care, or control during
present attack: .
When and where under oversight, care, or control during
previous attacks: .
Whether epileptic or not: .
Whether suicidal or not: .
Whether dangerous to others, and (if so) in what
way: .
Whether any near relative of said person has at any time
been or now is of unsound mind, or mentally infirm,
or idiot, imbecile, feeble-minded, or markedly eccentric;
or has suffered, or now suffers from—(a) epilepsy,
(b) hysteria, (c) neurasthenia, (d) spasmodic asthma,
(e) chorea, or (f) alcoholism. If so, state degree of re-
lationship and particulars as to complaint: .

Relatives of said Person.

In my opinion the following of the above-mentioned re-
lative are in a position to contribute to the maintenance
of the said person: .
Name and address of person to whom official communi-
cations should be addressed: .
Name and address of usual medical attendant of
mentally defective person: .
[This application is accompanied by a medical certificate
by , of , dated the* day of ,
191 .]
[Ordinary signature of applicant.]

• Any such application may be accompanied by a medical certi-
  ficate in the prescribed form, bearing a date not earlier than three
  days before the date of the application.—Section 4 (3).

STATUTORY DECLARATION.
(To be completed if required by Magistrate hearing
application.)
Under Section 4 (5) of the Mental Defectives Act, 1911.
I, [Name in full], a [Occupation], of [Address], do solemnly
and sincerely declare that the statements contained in the
foregoing application for a reception-order for the deten-
tion of [Name in full, occupation, and address] under the
Mental Defectives Act, 1911, are true.
And I make this solemn declaration conscientiously be-
lieving the same to be true, and by virtue of the Justices
of the Peace Act, 1908.
[Signature.]
Declared at , this day of , 191 ,
before me , a Justice of the Peace [or Solicitor].

[Form No. 2.

MEDICAL CERTIFICATE.
Under the Mental Defectives Act, 1911.
I, [Name in full], being a medical practitioner duly regis-
tered in New Zealand, and residing at [Address in full],
do hereby certify that on the day of ,
191 , at [Place of examination], I personally examined
[Full name], a [Occupation], of [Address], and am of
opinion that [s]he is a mentally defective person within
the meaning of the above-mentioned Act, and requires
detention as such. [In cases of urgency, where it is
expedient either for the welfare of the person in respect
of whom the application is made or in the public interest
that the said person should be placed under care and treat-
ment before a reception-order can be obtained, add: I
hereby further certify that the matter is one of urgency.]
[Where application is being made for detention in private
house, add: I hereby further certify that it would be safe
and convenient that the said person should be received
and detained as a single patient under the said Act, in-
stead of in an institution.]

• Delete and initial matter in brackets if inapplicable.

1. The following are the facts observed by me on the
   occasion of the examination aforesaid, on which my
   opinion is based: .
2. In pursuance of section 11 of the said Act, I make
   this further statement with respect to the said person:—
   (a.) The following facts, indicating mental defect on the
   part of the said person, have been observed by me
   on occasions other than the date of examination
   aforesaid: [Set out date of observation and facts
   observed].
   (b.) The following facts concerning the said person, in-
   dicating mental defect, have been communicated
   to me by [Set out facts communicated by other
   persons, together with the names and addresses of
   such persons].
   (c.) In my opinion the said person may be properly
   classified as being of unsound mind [or mentally
   infirm, or an idiot, or imbecile, or feeble-minded,
   or epileptic].
   (d.) In my opinion the factors which have caused the
   mental defect of the said person are the follow-
   ing: .
   (e.) In my opinion the said person is [or is not] suicidal.
   (f.) In my opinion the said person is [or is not] dan-
   gerous.
   (g.) The following treatment has been employed for the
   said person in respect of his mental condition:
   [Describe treatment, if any].
   (h.) The said person’s present bodily health and con-
   dition are as follows: [Describe bodily condition,
   &c., with special reference to the presence or
   absence of communicable disease or recent injury].
   I hereby declare that I am not prohibited by the * Mental
   Defectives Act, 1911, from signing this certificate.
   † Dated at , this day of , 19 .
   [Signature of Medical Practitioner.]

• See section 12, subsections (1) and (2).
  † Every such medical certificate shall bear date of the day on
  which the certifying medical practitioner last examined the person
  alleged to be mentally defective before the signing of the certifi-
  cate.—Section 5 (5).

PARTICULARS TO BE SUPPLIED BEFORE FORM OF CERTIFICATE
ISSUED TO MEDICAL PRACTITIONER FOR COMPLETION.

Name in full, occupation, and address of person in respect
of whom application is made: .
Name in full, occupation, and address of applicant for
reception-order: .
Institution or house in which, if order made, patient will
be received: .
Name of Superintendent, Medical Officer, licensee, or
householder: .