Schedule. (2), The Lunacy Ordinance

FORM A. CERTIFICATE OF LUNACY. We, the undersigned, being duly qualified medical practitioners, and being in actual practise as such within the Colony of... ....................................... do hereby certify that we on _the .......................................... day of.......................................... at ................................... . not jointly with each other, and separately from any medical practitioner, personally examined ......................................... and that the said........................................ ..is a person of unsound mind and a proper person to be taken charge of, and detained under care and treatment and we formed this opinion upon the following grounds, viz.:- 1. Facts indicating insanity observed by ourselves. 2. Other facts (if any) indicating insanity communicated to us by others. Sec. 18. Sec. 20. STATEMENT OF PARTICULARS. (If any of the particulars in this statement be not known the fact to be so stated) (1) N arne of patient, country or nationality in full. (2) Sex and age. (3) Married, single, widow or a widower. (4) Condition of life, and occupation, if any. (5) Religious persuasion, as far as known. (6) Previous place of abode. (7) Whether present is first attack. (8) Age on first attack. (9) When and where previously under care and treatment. (10) Duration of existing attack. (11) Supposed cause. (12) Whether subject to epilepsy. (13) Whether suicidal. (14) Whether dangerous to others. (15) Whether found lunatic by inquisition, and date of commission or order for inquisition. (16) Special circumstances (if any) preventing the patient being examined before admission separately by two medical practitioners. ORDER OF REMOVAL. I (or We) .................................................................. Chief Justice of the Supreme Court of Sierra Leone (or Judge, Police Magistrate, or Justices of the Peace, as the. case may be), do hereby order the removal of... ................................. to the mental hospital at .......................................... to be detained there until the further order of the Court. (Signed) To ........................................ Medical Superintendent. FoRM B. CERTIFICATE OF EMERGENCY. I certify that it is expedient for the welfare of... ....................................... that the said .......................................... should be forthwith placed under observation and treatment for a period not exceeding.................................... days. My reasons for this conclusion are as follows:-(Here state them.) To .......................................... Medical Superintendent. (Signed) ~·· Lunacy [Cap. 157 1665 -------------------------------------------------------------------- FORM c. CERTIFICATE OF SANITY. We hereby certify that we have this day, not jointly with each other, and separately from any medical practitioner, personally examined ............................ .. at present confined in the mental hospital at .......................................... and after due inquiry into all necessary facts relating to his case, we believe that he is now of sufficiently sound mind as to be a proper person to be discharged therefrom. (Signed) ORDER OF DISCHARGE. I (or We) ................................................................. Chief Justice of the Supreme Court of Sierra Leone (or Judge, Police Magistrate, or Justices of the Peace, as the case may be), do hereby order the discharge of. ........................................ .from the mental hospital at .......................................... . (Signed) To ..........................................Medical Superintendent. Sec. 23.