Feb. 29.] THE NEW ZEALAND GAZETTE. 895

STATUTORY DECLARATION BY APPLICANT.

I, [Name in full, occupation, and address], do hereby solemnly and sincerely declare that the statements in the foregoing application under the Mental Defectives Act, 1911, for the reception and detention in an institution under the said Act, of [Name in full], being a person under the age of twenty-one years and alleged to be mentally defective, are true.

And I make this solemn declaration conscientiously believing 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. 7.

JOINT MEDICAL CERTIFICATE FOR RECEPTION OF MINOR.

Under the Mental Defectives Act, 1911.

WE, , of , and , of , being medical practitioners duly registered in New Zealand, do hereby certify that on the day of , 191 , at , we examined [Full name and description], a person under the age of twenty-one years, and are of opinion that the said person is mentally defective, and requires detention as such.

The following are the facts observed by us on the occasion of the examination aforesaid, on which our opinion is based :

Dated at , this day of , 191 .

[Signatures.]

ADDITIONAL PARTICULARS TO BE SUPPLIED BY CERTIFYING MEDICAL PRACTITIONERS.

NOTE.—Any particulars within the knowledge of one only of the certifying medical practitioners should be supplied by him, and initialled. Particulars not so initialled will be regarded as expressing the knowledge or opinion of both practitioners.

1. The following facts, indicating mental defect on the part of the said person, have been observed by us on occasions other than the date of examination above referred to : [Set out date of observation and facts observed].

2. The following facts concerning the said person, indicating mental defect, have been communicated to us by others : [Set out facts communicated by other persons, together with the names and addresses of such persons].

3. In our 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].*

4. In our opinion the factors which have caused the mental defect of the said person are the following :

5. In our opinion the said person is [or is not] suicidal.

6. In our opinion the said person is [or is not] dangerous.

7. The following treatment has been employed for the said person in respect of his mental condition : [Describe treatment, if any].

8. The said person’s present bodily health and condition are as follows : [Describe bodily condition, &c., with special reference to the presence or absence of communicable disease or recent injury].

[Signatures.]

• see definition of “mentally defective person.”—Section 2.

Excerpt from the Mental Defectives Act, 1911.

2. “Mentally defective person” means a person who, owing to his mental condition, requires oversight, care, or control for his own good or in the public interest, and who according to the nature of his mental defect, and to the degree of oversight, care, or control deemed to be necessary, is included in one of the following classes :—

Class I.—“Persons of unsound mind”—that is, persons who, owing to disorder of the mind, are incapable of managing themselves or their affairs.

Class II.—“Persons mentally infirm”—that is, persons who, through mental infirmity arising from age or the decay of their faculties, are incapable of managing themselves or their affairs.

Class III.—“Idiots”—that is, persons so deficient in mind from birth or from an early age that they are unable to guard themselves against common physical dangers and therefore require the oversight, care, or control required to be exercised in the case of young children.

Class IV.—“Imbeciles”—that is, persons who though capable of guarding themselves against common physical dangers are incapable, or if of school age will presumably when older be incapable, of earning their own living by reason of mental deficiency existing from birth or from an early age.

Class V.—“Feeble-minded”—that is, persons who may be capable of earning a living under favourable circum-

stances, but are incapable from mental deficiency existing from birth or from an early age of competing on equal terms with their normal fellows, or of managing themselves and their affairs with ordinary prudence.

Class VI.—“Epileptics”—that is, persons suffering from epilepsy.

[Form No. 8.

REQUEST FOR ADMISSION TO INSTITUTION AS VOLUNTARY BOARDER.

Under the Mental Defectives Act, 1911.

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

I, [Name in full], a [Occupation], of [Address in full], hereby request you to admit and detain me in the above-mentioned institution for care and treatment as a voluntary boarder therein. I am aware that as a consequence of signing this request I am liable to be detained in the said institution for seven days after the receipt by you of a written application by me to be discharged.

My reason for seeking admission is .

In case of illness or other emergency, communicate with [Name and address of relative or friend].

I am years of age, and am [State whether single, married, widowed, or divorced].

Dated at , this day of , 191 .

[Ordinary signature of applicant.]

NOTE.—Where detention is in a public institution, state here what provision is made by or on behalf of boarder for maintenance during detention : .

[Form No. 9.

PRELIMINARY STATEMENT AS TO MENTAL AND BODILY CONDITION OF [Name of Patient].*

Under Section 66 (2) of the Mental Defectives Act, 1911.

I HAVE this day examined the above-named person, and certify with respect to his [her] mental condition as follows : [Review the statements as to the mental condition of the patient made in the application and medical certificates].

And with respect to his [her] bodily condition, I hereby certify as follows : [Set out facts as to apparent bodily condition, making special reference to communicable disease and recent injuries].

Dated at . this day of , 191 .

, Medical Officer.

• Within twenty-four hours after the admission of a patient the Superintendent shall send to the Inspector-General a preliminary statement as to the mental and bodily condition of the patient in the prescribed form, signed by the Medical Officer.—Section 66 (2).

[Form No. 10.

MEDICAL VISITATION BOOK.

Under Section 20 of the Mental Defectives Act, 1911 (relating to Single Patients).

Name of householder : .

Address : .

NAME of patient : .

Physical health and condition : .

Mental condition : .

Change (if any) in physical or mental condition since last visit, with particulars : .

Whether special treatment (if any prescribed) has been satisfactorily carried out : .

Nature of such treatment : .

Special treatment (if any) now recommended : .

Has mechanical restraint been resorted to? ; if so, state particulars : .

Has seclusion been resorted to? ; if so, state particulars : .

Number of persons occupying same bedroom as patient : .

Cubic capacity (approximately) of such room : .

Sanitary conditions of house : .

Other particulars : .

Date of visit : .

[Signature of Medical Practitioner.]

[Form No. 11.

WARRANT TO APPREHEND.

Under the Mental Defectives Act, 1911.

To , constable, and to all other constables of of .

WHEREAS application for a reception-order in respect of [Name in full], a [Occupation], of [Address], has been made to me in pursuance of the above-mentioned Act : And whereas it is expedient that the said [Name in full]