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Continuing Detention Order with Treatment Order

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					                                                                                    MENTAL HEALTH ACT 1993

                                                                   Application form for a:
              Continuing Detention Order
                                 with accompanying Treatment Order
What is this form for?
  Continuing Detention Order with accompanying Treatment Order (CDO/TO)
  Apply for this Order if you require permission to detain a person in a hospital for psychiatric treatment
  for up to 12 months. The Board can only make an order if the patient is already under a short-term
  detention order made pursuant to Section 12 of the Act and if there is a need to continue the detention
  in the interests of the person's own health and safety and/or for the protection of others.
Legal rights
  Any person who is subject of an application to the Guardianship Board needs to be aware of their legal
  rights at the hearing, which include the following:
  ·      their right to be represented by counsel, the Public Advocate, a recognised advocate or, with the
         leave of the Board, any other representative/support person;
  ·      their right to call or give evidence or present other evidence/material to the Board;
  ·      their right to examine or cross-examine witnesses;
  ·      their right to make oral or written submissions to the Board;
  ·      their right to engage an interpreter; and
  ·      their right to request an adjournment.

Who can apply?
  Continuing Detention Order with accompanying Treatment Order (CDO/TO)
  Applicants for a Continuing Detention Order with accompanying Treatment Order can only be:
  1) The Director of an Approved Treatment Centre; or
  2) An employee of an Approved Treatment Centre authorised to make an application; or
  3) A person duly authorised to admit patients to an Approved Treatment Centre; or
  4) The Public Advocate.

Do you need an interpreter?
  If you or the person applying require this form explained in another language please call the Telephone
  Interpreter Service (TIS) on 13 14 50 and ask them to contact the Guardianship Board on 8368 5600.

For more information and advice
  For advice please contact the Office of the Public Advocate on 8342 8200

Where to lodge an application
      Guardianship Board                             Telephone:           8368 5600
      Level 8 ABC Building                           SA Country Callers:  1800 80 05 01
      85 North East Road                             Facsimile:           8368 5699
      COLLINSWOOD SA 5081                            Email: guardianshipboard@agd.sa.gov.au

      PO Box 138                                     www.guardianshipboard.sa.gov.au
      PROSPECT SA 5082
                                                                                                             application page 1 of
                                                       Continuing Detention Order with Treatment Order (v1.3)Version 1.3 Updated 4/3/20105
 A copy of this application will be provided to the person it is about


  1      Patient details                                                                                     CDO
 Title      Family name                                     Given names


                                                                                              Day        Month          Year
 Broad psychiatric diagnosis
                                                                              Date of
                                                                                                     /            /
                                                                                birth
 Authorised Treatment Centre address - street name and number


 Suburb                                   State             Postcode                Daytime phone number


 Home address - street name and number


 Suburb                                   State             Postcode                Daytime phone number


 Language spoken at home                                    Aboriginal or Torres Strait Islander
                                                                            Yes                     No



 2       Applicant details

Title      Family name                                     Given names


Responsible clinical team or region                         Professional relationship to patient


Postal address


Suburb                                  State            Postcode                 Daytime phone number


Email address                                                                     Mobile phone number



 Please indicate your availability for a hearing   Dates unavailable or new doctor taking over
          MON    TUE      WED    THU      FRI
  AM

  PM


                                                      Continuing Detention Order with Treatment Order (v1.3) application page 2 of 5
 3     Proposed duration of Detention Order with Treatment Order

  Continuing Detention Order
                                                      Proposed duration
  with Treatment Order
                                                                                           maximum 12 months

                                              I have attached the current detention forms

 4      Communication

Please specify below if there are special communication requirements, i.e. interpreter, AUSLAN, etc.
     Yes
     No



 5     Report provided by psychiatrist

A medical report must accompany applications for a Continuing Detention Order with Treatment Order.
The report is to address the elements outlined in Section 13 and/or Section 20 of the Mental Health Act
1993 and identify the sources of information contained in the report, as set out below.

Please attach a separate report to the Board that addresses the following criteria:

    Mental illness
    - Current diagnosis, when it was made and by whom
    - Any prior diagnoses and when they were made
    - A brief history of the course of the illness of this patient


   Hospitalisation and detention
   - Summary of current and recent hospitalisations and detentions



    Amenability to treatment
    - Outline past treatments and response to these treatments
    - Current treatment and response to current treatment



    Treament for patient's safety and/or the protection of others
    - Previous incidents of risk to the patient's own health and safety, when they occured, and the
      source of this information.
    - Previous incidents of risk or threat and need for protection of others, when they occured, and the
      source of this information.


   Reason why treatment should occur in hospital



                                                         Continuing Detention Order with Treatment Order (v1.3) application page 3 of 5
 6       Clinical team details (other than the applicant)

Name                                                                 Work phone

Clinical role                                                        Mobile phone

Work address

Suburb                                                                                    Postcode

Email




Name                                                                 Work phone

Clinical role                                                        Mobile phone

Work address

Suburb                                                                                    Postcode

Email




Name                                                                  Work phone

Clinical role                                                         Mobile phone

Work address

Suburb                                                                                    Postcode

Email




Name                                                                  Work phone

Clinical role                                                         Mobile phone

Work address

Suburb                                                                                    Postcode

Email


                                                Continuing Detention Order with Treatment Order (v1.3) application page 4 of 5
 7       Other people to invite to the hearing

Name                                                                          Daytime phone

Relationship                                                                  Mobile phone

Address

Suburb                                                                                            Postcode

Email

Name                                                                          Daytime phone

Relationship                                                                  Mobile phone

Address

Suburb                                                                                            Postcode

Email

Name                                                                          Daytime phone

Relationship                                                                  Mobile phone

Address

Suburb                                                                                            Postcode

Email


 8       Applicant's declaration and lodgement details
All information contained in this report must be made available to the patient who is the subject of this
application and their legal representative unless there is a good clinical reason why not (ie. serious risk to patient
or others).
I have completed all sections of this application. No information relevant to the application has been omitted.
The information provided to the Guardianship Board is true and correct to the best of my knowledge.
Name of treating medical officer                   Signature                                              Date



Name of applicant (if different from above) Signature                                                     Date



          Guardianship Board                                  Telephone: 8368 5600
          Level 8 ABC Building                                Facsimile: 8368 5699
          85 North East Road                                  Email: guardianshipboard@agd.sa.gov.au
          COLLINSWOOD SA 5081                                 www.guardianshipboard.sa.gov.au

                                                           Continuing Detention Order with Treatment Order (v1.3) application page 5 of 5

				
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