Petition for Order of Reception of Mentally iIl Person
The Metropolitan Magistrate/
Magistrate empowered under Act 14 of 1987
In the matter of AB of ……………… etc., a person alleged to be a mentally ill person under s. 2(m) of the Mental Health Act 1987
The petition of CD (full name, address and relationship) as follows:
1. I, the applicant, an …………….. years of age.
2. I desire to obtain an order for the reception of AB of, etc., as a mentally ill person in the Psychiatric Hospital/Nursing home at etc. etc.
3. I last saw AB at, etc., on the ……………………. day of ………………..
4. I am the ………….. (relationship) of the said AB.
The circumstances under which this petition is presented by the applicant are as follows, etc.
(Or, if the applicant is not a relative—That the applicant is not a relative of the said AB. The reasons why this petition is not presented by a relative are as follows, etc.)
5. The persons signing the medical certificates which accompany the application are, etc.
6. A statement of particulars relating to the said AB accompanies this petition.
7. An application for an enquiry into the mental capacity of the said AB was made to the, etc., on the …………… day of ……………, and a certified copy of the order made on the said application is annexed hereto.
(Or—No application for an enquiry into the mental capacity of the said AB has been made previous to this application).
I therefore pray that a reception order may be made in accordance with the foregoing statement.
The statement contained or referred to in paragraphs are true to my knowledge; the other statements are true to my information and belief.
The statement of particulars above referred to
The following is a statement of particulars relating to the said AB:
Name of patient in full.—
Sex and age.—
Married, single or widower.—
Caste and religion.—
Residence at the time of the application.—
Names of any near relative to the patient who are alive.—
Whether this is first attack of mental illness.—
Age on first attack.—
Whether the patient is subject to epilepsy.—
Whether the patient is known to be suffering from any form of tubercular disease.—
Whether dangerous to others and in what way.—
Whether any near relative (stating the relationship) has been afflicted with insanity.—
Whether the patient is addicted to alcohol or the use of opium, ganja, charas, bhang, cocaine or other intoxicant.—
(If any of the particulars in the above statement be not known, the fact to be so stated).