Schedule 1Medical certificate as to examination or observation of person

# Schedule 1 Medical certificate as to examination or observation of person Schedule 1 Medical certificate as to examination or observation of person (Section 19) **[Mental Health Act 2007](/view/html/inforce/current/act-2007-008)** **Part 1** I, \[*name in full—use block letters*\] (Medical Practitioner/accredited person) of certify that on \[*date*\] immediately before or shortly before completing this certificate, at \[*state place where examination/observation took place*\] I personally/by audio visual link examined/personally/by audio visual link observed \[*name of person in full*\] for a period of \[*state length of examination/observation*\]. I certify the following matters— > 1. I am of the opinion that the person examined/observed by me is \[*strike out alternative that is not applicable*\]— > > > (a) a mentally ill person suffering from a mental illness and that owing to that illness there are reasonable grounds for believing that care, treatment or control of the person is necessary for the person’s own protection from serious harm or for the protection of others from serious harm, > > > (b) a mentally disordered person whose behaviour for the time being is so irrational as to justify a conclusion on reasonable grounds that temporary care, treatment or control of the person is necessary for the person’s own protection from serious physical harm or for the protection of others from serious physical harm. > 2. I have satisfied myself, by such inquiry as is reasonable having regard to the circumstances of the case, that the person’s involuntary admission to and detention in a mental health facility are necessary and that no other care of a less restrictive kind is appropriate and reasonably available to the person. > 3. Incidents and/or abnormalities of behaviour and conduct (a) observed by myself and (b) communicated to me by others (state name, relationship and address of each informant) are— > > > (a) ............................................................ > > ............................................................ > > ............................................................ > > ............................................................ > > ............................................................ > > > (b) ............................................................ > > ............................................................ > > ............................................................ > 4. The general medical and/or surgical condition of the person is as follows— > ............................................................ > ............................................................ > ............................................................ > ............................................................ > 5. The following medication (if any) has been administered for purposes of psychiatric therapy or sedation— > ............................................................ > ............................................................ > ............................................................ > 6. I am not a near relative or a designated carer or the principal care provider of the person. > 7. I have/do not have a pecuniary interest, directly or indirectly, in a private mental health facility. I have/do not have a near relative/partner/assistant who has such an interest. Particulars of the interest are as follows— > ............................................................ > ............................................................ > ............................................................ Made and signed this \[*date*\] \[*Signature*\] **Part 2** The following persons may transport a person to a mental health facility: a member of staff of the NSW Health Service, an ambulance officer, a police officer. If the assistance of a police officer is required, this Part of the Form must be completed. YOU SHOULD NOT REQUEST THIS ASSISTANCE UNLESS THERE ARE SERIOUS CONCERNS RELATING TO THE SAFETY OF THE PERSON OR OTHER PERSONS IF THE PERSON IS TAKEN TO A MENTAL HEALTH FACILITY WITHOUT THE ASSISTANCE OF A POLICE OFFICER I have assessed the risk and I am of the opinion, in relation to \[*name of person in full*\] that there are serious concerns relating to the safety of the person or other persons if the person is taken to a mental health facility without the assistance of a police officer. The reason for me being of this opinion is \[*include any information known about the patient relevant to the risk*\]. Made and signed this \[*date*\] \[*Signature*\] Notes **sch 1:** Am 2014 No 85, Sch 1 \[82\] (am 2015 No 15, Sch 1.18 \[2\]) \[83\]–\[86\] (am 2015 No 15, Sch 1.18 \[3\]) \[87\]; 2025 No 48, Sch 2.8.