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[接上页] [If the mentally incapacitated person is a patient detained under the Mental Health Ordinance]* The mentally incapacitated person is detained or liable to be detained under section .................................... of the Mental Health Ordinance. [If the mentally incapacitated person is the subject of a recommendation under section 59E(4)(a)(iii) or (6)(a) of the Mental Health Ordinance]* Details of the recommendation (including the order which the mentally incapacitated person is subject to) are as follows- .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. Reason for making the application I (the applicant) have reason to believe- (a) the mentally incapacitated person the subject of this application is suffering from mental disorder/has a mental handicap* of a nature of degree which warrants his/her reception into guardianship under Part IVB of the Mental Health Ordinance; and (b) it is necessary in the interests of the welfare of the mentally incapacitated person or for the protection of other persons that the mentally incapacitated person should be so received;The reasons for my belief are- .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. .............................................................................................................................................. I (the applicant) apply for the person to be received into the guardianship of [proposed guardian's name] ............................................ in accordance with section 59O of the Mental Health Ordinance. This application is accompanied by and founded on the attached written reports of 2 registered medical practitioners (neither of whom is the applicant) in accordance with section 59M(3) of the Mental Health Ordinance (See Note 3). Particulars of the 2 registered medical practitioners are as follows- 1. Name: ............................................................................. Address: ........................................................................................................................ Length of period of caring for the mentally incapacitated person: ....................................... Approved under section 2(2) of the Mental Health Ordinance: Yes/No*2. Name: ............................................................................. Address: ........................................................................................................................ Length of period of caring for the mentally incapacitated person: ....................................... Approved under section 2(2) of the Mental Health Ordinance: Yes/No* Signature of the applicant ............................................ Date ............................................ PART II Information on proposed guardian where the proposed guardian is not the Director of Social Welfare Name: ........................................................................ Sex: (M/F) Age: ...................... Identity card no.: ......................................................... Address: ................................................................................................................................ PART III Declaration by proposed guardian where the proposed guardian is not the Director of Social Welfare I, the proposed guardian, am willing to act as the guardian of [name of the mentally incapacitated person] ......................................................................................................... in accordance with section 59O of the Mental Health Ordinance. I (the proposed guardian) am the [state relationship] .................................................... of the mentally incapacitated person. Signature of the proposed guardian ............................................ Date ............................................ * Delete as appropriate. Notes: 1. Delete this paragraph if the applicant is a relative of the mentally incapacitated person. |