Form 3 "Reference of Person's Mental State to the Mental Health Court" - Queensland, Australia

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MENTAL HEALTH COURT
Reference of person’s mental state to the
Mental Health Court
Mental Health Act 2016, sections 101, 104, 110-111, 175-176, 183-184
Approved form no.: 3, version 1.1, 03/2017
Proceeding number:
Email:
registrarmhc@health.qld.gov.au
Section 1 - Person being referred
Surname:
Given name(s):
Also known as:
Date of birth
:
Age:
(DD/MM/YYYY)
or
Address:
Town / Suburb:
State:
Postcode:
Email address:
Contact number:
Section 2 - Details of offence(s), including summary offences
Court file number /
Date of offence
Number
Offence
Court
indictment number
(DD/MM/YYYY)
1
2
3
4
5
Additional schedule of offences is attached
Section 3 - Further details
Has an examination order been made?
Yes
No
Unknown
If yes, name of authorised mental health service or public sector health service facility where person to be examined:
Has the person been remanded in custody?
Yes
No
Unknown
If yes, name of correctional facility:
Has the person been granted bail?
Yes
No
Unknown
If yes, provide bail address:
Is the person being treated in an authorised mental health service?
Yes
No
Unknown
If yes, name of authorised mental health service:
Page 1 of 2
MENTAL HEALTH COURT
Reference of person’s mental state to the
Mental Health Court
Mental Health Act 2016, sections 101, 104, 110-111, 175-176, 183-184
Approved form no.: 3, version 1.1, 03/2017
Proceeding number:
Email:
registrarmhc@health.qld.gov.au
Section 1 - Person being referred
Surname:
Given name(s):
Also known as:
Date of birth
:
Age:
(DD/MM/YYYY)
or
Address:
Town / Suburb:
State:
Postcode:
Email address:
Contact number:
Section 2 - Details of offence(s), including summary offences
Court file number /
Date of offence
Number
Offence
Court
indictment number
(DD/MM/YYYY)
1
2
3
4
5
Additional schedule of offences is attached
Section 3 - Further details
Has an examination order been made?
Yes
No
Unknown
If yes, name of authorised mental health service or public sector health service facility where person to be examined:
Has the person been remanded in custody?
Yes
No
Unknown
If yes, name of correctional facility:
Has the person been granted bail?
Yes
No
Unknown
If yes, provide bail address:
Is the person being treated in an authorised mental health service?
Yes
No
Unknown
If yes, name of authorised mental health service:
Page 1 of 2
MENTAL HEALTH COURT
Reference of person’s mental state to the
Mental Health Court
Mental Health Act 2016, sections 101, 104, 110-111, 175-176, 183-184
Approved form no.: 3, version 1.1, 03/2017
Proceeding number:
Email:
registrarmhc@health.qld.gov.au
Section 4 - Signature of person making reference
Chief Psychiatrist
Director of Forensic Disability
Person subject of the reference
Person’s lawyer
Director of Public Prosecutions
Registrar of Magistrates Court
Registrar of Supreme Court
Registrar of District Court
The matter of the person’s mental state relating to the offence(s) is referred to the Mental Health Court.
Attached is a copy of the report (if any) relating to the person’s mental state.
Attachment(s) included?
Yes
No
Name:
Position:
Date
:
Signature or seal:
(DD/MM/YYYY)
Contact number:
Address:
Town / Suburb:
State:
Postcode:
TO: Registrar, Mental Health Court
registrarmhc@health.qld.gov.au; GPO Box 48, Brisbane, QLD, 4001
NOTE: by sending this form by email, you consent to the Mental Health Court using email to communicate with
you, including sending you notices under the Mental Health Act 2016.
Section 5 - Signature of registrar, Mental Health Court
Signature:
[seal]
Name:
Date
:
(DD/MM/YYYY)
Note: the proceeding for the offence(s) under chapter 15, part 2 of the Mental Health Act 2016 is suspended.
TO: Person the subject of the reference or, if known, the person’s lawyer
Director of Public Prosecutions
Chief Psychiatrist
Chief Executive (Justice)
Director of Forensic Disability
If the person the subject of the reference is a child within the meaning of the Youth Justice Act 1992 - the
Chief Executive (Youth Justice)
If known, any nominated support person, personal guardian or attorney for the person the subject of the
reference
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