894
THE NEW ZEALAND GAZETTE.
[No. 19

[Form No. 5.
REQUEST FOR RECEPTION INTO INSTITUTION OF PERSON
ALLEGED TO BE MENTALLY DEFECTIVE BEFORE A RECEPTION-
ORDER CAN BE OBTAINED.

Under the Mental Defectives Act, 1911.

To the Superintendent of the [Name of institution],
situate at

I, [Full name], a [Occupation], of [Address in full], being
a person not under twenty-one years of age, hereby re-
quest you to receive [Full name], a [Occupation], of [Ad-
dress in full] (hereinafter in this request referred to as
“the said person”) in the [Name of institution], situate
at
, on the grounds that the said person is mentally
defective, and it is expedient for his [her] own welfare,
or in the public interest, that he [she] should be placed
under care and treatment before a reception-order can
be obtained.

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 request is
   made by me [because I am the nearest relative; or, if
   applicant is not a relative or nearest relative, state why
   request is made by the applicant instead of by a relative
   or a nearer relative, the degrees of relationship being
   determined 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].

3. I have seen the said person within three days from
   the date of this request—namely, on the
   day of
   , 191
   .

Dated at
, the
day of
, 191
.

[Ordinary signature of applicant.]

N.B.—This request must be accompanied by a certificate in the
prescribed form, signed by one medical practitioner.

No person is to be received into an institution in pursuance of
such request after the expiration of seven days from the date
thereof, or from the date of the medical certificate, whichever date
is the earlier.

FURTHER PARTICULARS TO BE SUPPLIED BY APPLICANT AS TO
PERSON IN RESPECT OF WHOM REQUEST 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, and control during
present attack:
.
When and where under oversight, care, and 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
relationship and particulars as to complaint:
.

Relatives of said Person.

In my opinion the following of the above-mentioned
relatives 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:
.

[Ordinary signature of applicant.]

—

[Form No. 6.
APPLICATION FOR RECEPTION AND DETENTION OF MINOR IN
AN INSTITUTION.

Under the Mental Defectives Act, 1911.

To the Inspector-General of Mental Defectives, at Wel-
ington.

I, [Full name], a [Occupation], of [Address], being the
father [or mother, or guardian, as the case may be] of
[Name in full], a person under the age of twenty-one years,
hereby apply for an order for the reception and detention
of the said
as a mentally defective person in the
[Name of institution], situate at
, or in such other
similar institution as may be directed.

I hereby declare that I am for the time being entitled
to the custody or guardianship of the said
.

I believe that the said person is mentally defective,
upon the grounds following: [Set out in full the reasons
for the applicant’s belief].

I forward herewith a medical certificate signed by
Doctors
, of
, and
, of
, 191
.

Dated at
, the
day of
, 191
.

[Ordinary signature of applicant.]

FURTHER PARTICULARS AS TO MINOR TO BE SUPPLIED BY
APPLICANT TO THE BEST OF HIS KNOWLEDGE AND BELIEF.

Date of birth:
.

Sex:
.

Country of birth:
.

If not born in New Zealand, date of arrival:
.

Nationality of parents:
.

Age of parents at birth of child:
.

Whether either parent was in ill health, or addicted to
the use of intoxicants, at or about the time of concep-
tion:
.

What were the mental and physical condition and the
habits of the mother during pregnancy?
.

When said person first deemed to be mentally defec-
tive:
.

Where resident at that time:
.

Mental condition (present and past), with special reference
to—(a) habits; (b) reaction to training and education;
(c) any change in mental state; and (d) any other par-
ticulars:
.

Physical condition, with special reference to—(a) con-
dition at birth (with special circumstances, if any);
(b) mode of nurture during infancy; (c) convulsions,
epilepsy, and other ailments; and (d) state of present
health:
.

When and where under oversight, care, or control since
attaining age of seven years:
.

Whether any near relative 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) neuras-
thenia, (d) spasmodic asthma, (e) chorea, or (f) alco-
holism. If so, state degree of relationship, and par-
ticulars as to complaint:
.

Relatives of Minor.

What amount can you pay weekly towards the mainten-
ance of the said person?
.

Which of the above relatives are, in your opinion, in a
position to contribute towards the balance of such main-
tenance?
.

Name of usual medical attendant:
.

[Ordinary signature of applicant.]