Schedule 1 Medical certificate as to examination of inmate

Schedule 1 Medical certificate as to examination of inmate

(Section 86(3))

Mental Health and Cognitive Impairment Forensic Provisions Act 2020

I, [name in full—use block letters] (*Medical Practitioner/Psychiatrist) of do certify that on [date] at [state place where examination took place], separately from any other medical practitioner, I personally examined [name of inmate in full] *detained at [name of correctional centre or detention centre where inmate is imprisoned or detained if not the place where the examination took place], and I am of the opinion that *he/she is *a mentally ill person/a person who has a condition for which treatment is available in a mental health facility.

I have formed this opinion on the following grounds—

(1) Facts indicating *mental illness/condition observed by myself.
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(2) Other relevant information (if any) communicated to me by others (state name and address of each informant).
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Made and signed this [date]

[Signature]

*Delete whichever does not apply.

sch 1: Am 2022 No 6, Sch 1.4.