Schedule 2 Dependency certificate

Schedule 2 Dependency certificate

(Section 9 (2))

Drug and Alcohol Treatment Act 2007

Part 1

I, [name in full—use block letters] (accredited medical practitioner) of [address] certify that on [date] immediately before, or shortly before, completing this certificate, I personally assessed [name of person in full] under section 9 of the Drug and Alcohol Treatment Act 2007 at [state place where assessment took place] for a period of [state length of assessment].

I certify the following matters—

1. I am of the opinion that—

(a) the person I assessed (the dependent person) has a severe substance dependence, and

(b) care, treatment or control of the person is necessary to protect the person from serious harm, and

(c) the person is likely to benefit from treatment for his or her substance dependence but the person has refused treatment, and

(d) no other appropriate and less restrictive means for dealing with the person are reasonably available.

2. The following incidents and/or abnormalities of behaviour have been observed by me and/or communicated to me by others (state name, relationship and address of each informant)—

3. The general medical and/or surgical condition of the dependent person is as follows—

4. The following medication (if any) has been administered for the purposes of treating the dependent person—

5. I am of the opinion the dependent person should be detained for 28* days for treatment under the Drug and Alcohol Treatment Act 2007.

(* lesser days may be inserted in item 5 by the accredited medical practitioner)

6. I am not a near relative or the primary carer of the dependent person.

Signed this day of 20