Lunacy Act, 1890

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THE SECOND SCHEDULE.

Form 1.

Sects. 4, 5.

Petition for an Order for reception of a Private Patient.

In the matter of A.B. a person alleged to be of unsound mind.

To a justice of the peace for [or

To His Honour the judge of the county court of or To stipendiary magistrate for.]

The petition of C.D. of [¹] in the county of .

1. I am [²] years of age.

2. I desire to obtain an order for the reception of A.B. as a lunatic [³] in the asylum [or hospital or house as the case may be] of situate at [⁴]

3. I last saw the said A.B. at on the [⁵] day of

4. I am the [⁶] of the said A.B. [or if the petitioner is not connected with or related to the patient state as follows:]

I am not related to or connected with the said A.B. The reasons why this petition is not presented by a relation or connection are as follows: [State them.]

The circumstances under which this petition is presented by me are as follows: [State them.]

5. I am not related to or connected with either of the persons signing the certificates which accompany this petition as (where the petitioner is a man) husband, father, father-in-law, son, son-in-law, brother, brother-in-law, partner or assistant, (or where the petitioner is a woman) wife, mother, mother-in-law, daughter, daughter-in-law, sister, sister-in-law, partner or assistant.

6. I undertake to visit the said A.B. personally or by some one specially appointed by me at least once in every six months while under care and treatment under the order to be made on this petition.

7. A statement of particulars relating to the said A.B. accompanies this petition.

If it is the fact add:

8. The said A.B. has been received in the

asylum [or hospital or house as the case may be] under an urgency order dated the

The petitioner therefore prays that an order may be made in accordance with the foregoing statement.

[Signed]

full Christian and surname.

[¹ Date of the presentation of the petition.]

Sects. 4, 5, 11.

Form 2.

Statement of Particulars.

Statement of particulars referred to in the annexed petition [or in the above or annexed order].

The following is a statement of particulars relating to the said A.B. [¹] :—

Name of patient, with Christian name at length.

Sex and age.

†Married, single, or widowed.

†Rank, profession, or previous occupation (if any).

†Religious persuasion.

Residence at or immediately previous to the date hereof.

†Whether first attack.

Age on first attack.

When and where previously under care and treatment as a lunatic, idiot, or person of unsound mind.

†Duration of existing attack.

Supposed cause.

Whether subject to epilepsy.

Whether suicidal.

Whether dangerous to others, and in what way.

Whether any near relative has been afflicted with insanity.

Names, Christian names, and full postal addresses of one or more relatives of the patient.

Name of the person to whom notice of death to be sent, and full postal address if not already given.

Name and full postal address of the usual medical attendant of the patient.

(Signed)

Sect. 6.

Form 3.

Order for reception of a private patient to be made by a Justice appointed under the Lunacy Act, 1890, Judge of County Courts, or Stipendiary Magistrate.

I, the undersigned E.F., being a Justice for

specially appointed under the Lunacy Act, 1890 [or the Judge of the County Court of

or the Stipendiary Magistrate for

] upon the petition of C.D., of [¹]

in the matter of A.B. a lunatic, [²] accompanied by the medical certificates of G.H. and I.J. hereto annexed, and upon the undertaking of the said C.D. to visit the said A.B. personally or by some one specially appointed by the said C.D. once at least in every six months while under care and treatment under this order, hereby authorise you to receive the said A.B. as a patient into your asylum [³] . And I declare that I have [or have not] personally seen the said A.B. before making this order.

Dated

(Signed)

E.F.

A Justice for

appointed under the above-mentioned Act, [or The Judge of the County Court of

or a Stipendiary Magistrate.]

To [⁴]

Sect. 11.

Form 4.

Form of urgency Order for the reception of a private patient.

I, the undersigned, being a person twenty-one years of age, hereby authorise you to receive as a patient into your house [¹] A.B., as a lunatic [²] , whom I saw last at

on the [³]

day of

18

. I am not related to or connected with the person signing the certificate which accompanies this order in any of the ways mentioned in the margin [⁴] . Subjoined [or annexed] hereto [⁵] is a statement of particulars relating to the said A.B.

(Signed)

Name and Christian name at length

Rank, profession, or occupation (if any)

Full postal address

How related to or connected with the patient

[If not the husband or wife or a relative of the patient, the person signing to state as briefly as possible: 1. Why the order is not signed by the husband or wife or a relative of the patient. 2. His or her connexion with the patient, and the circumstances under which he or she signs.]

Describing the asylum, hospital, or house by situation and name.

Dated this

day of

18

.

To

superintendent of

the

asylum [

hospital or resident licensee of the

house].

Sect. 8.

Form 5.

Certificate as to Personal Interview after Reception.

I certify that it would be prejudicial to A.B. to be taken before or visited by a justice, a judge of county courts, or magistrate.

(Signed)

C.D.,

(Medical Superintendent of the

Asylum or Hospital or Resident Medical Practitioner or Attendant of the

, or Medical Attendant of the said A.B.

Sect. 8.

Form 6.

Notice of Right to Personal Interview.

Take notice that you have the right, if you desire it, to be taken before or visited by a justice, judge of county courts, or magistrate. If you desire to exercise such right, you must give me notice thereof by signing the enclosed form on or before the

day of

.

Dated

Signed

C.D.,

Superintendent of the

Asylum or Hospital or Resident Licensee of

[or as the case may be.]

Sect. 8.

Form 7.

Notice of Desire to have a Personal Interview.

Dated

[Address]

I desire to be taken before or visited by a justice, judge, or magistrate having jurisdiction in the district within which I am detained.

Signed

Sects. 4, 11, 16, 23, 24.

Form 8.

Certificate of Medical Practitioner.

In the matter of A.B. of [¹]

in the county [²] of [³] ,

an alleged lunatic.

I, the undersigned C.D., do hereby certify as follows:

1. I am a person registered under the Medical Act, 1858, and I am in the actual practice of the medical profession.

2. On the

day of

18

, at [⁴] in the county [⁵] of

[separately from any other practitioner] [⁶] , I personally examined the said A.B. and came to the conclusion that he is a [lunatic, an idiot, or a person of unsound mind] and a proper person to be taken charge of and detained under care and treatment.

3. I formed this conclusion on the following grounds, viz.:—

(a) Facts indicating insanity observed by myself at the time of examination [⁷] , viz.:—

(b) Facts communicated by others, viz.:—[⁸]

[If an urgency certificate is required it must be added here. See Form 9.]

4, The said A.B. appeared to me to be [or not to be] in a fit condition of bodily health to be removed to an asylum, hospital, or licensed house.[⁹]

5. I give this certificate having first read the section of the Act of Parliament printed below.

Dated

(Signed)

C.D., of [¹⁰]

Extract from section 317 of the Lunacy Act, 1890.

Any person who makes a wilful misstatement of any material fact in any medical or other certificate, or in any statement or report of bodily or mental condition under this Act, shall be guilty of a misdemeanor.

Sects. 11, 28.

Form 9.

Statement accompanying Urgency Order.

I certify that it is expedient for the welfare of the said A.B., [or for the public safety, as the case may be] that the said A B. should be forthwith placed under care and treatment.

My reasons for this conclusion are as follows: [state them].

Sect. 24.

Form 10.

Certificate as to Pauper Lunatic in a Workhouse.

I, the undersigned Medical Officer of

Workhouse of the

Union, hereby certify that I have carefully examined into the state of health and mental condition of A.B., a pauper in the said workhouse, and that he is in my opinion a lunatic, and a proper person to be allowed to remain in the workhouse as a lunatic, and that the accommodation in the workhouse is sufficient for his proper care and treatment separate from the inmates of the workhouse not lunatics [or, that his condition is such that it is not necessary for the convenience of the lunatic or of the other inmates that he should be kept separate].

The grounds for my opinion that the said A.B. is a lunatic are as follows:

Dated

(Signed)

Medical Officer of the Workhouse.

Form 11.

Sect. 24.

Order for detention of Lunatic in Workhouse.

I, the undersigned C.D., a justice of the peace for

being satisfied that A.B., a pauper in the

workhouse of the

is a lunatic [or idiot or person of unsound mind] and a proper person to be taken charge of under care and treatment in the workhouse, and being satisfied that the accommodation in the workhouse is sufficient for his proper care and treatment separate from the inmates of the workhouse not lunatics [or, that his condition is such that it is not necessary for the convenience of the lunatic or of the other inmates that he should be kept separate] hereby authorise you to take charge of, and, if the workhouse medical officer shall certify it to be necessary, to detain the said A.B. as a patient in your workhouse. Subjoined is a statement of particulars respecting the said A.B.

(Signed) C.D.,

A justice of the peace for

Dated

To the Master of the

Workhouse

of the

Statement of Particulars.

Name of patient and christian name at length.

Sex and age.

Married, single, or widowed.

Condition of life and previous occupation (if any).

Religious persuasion as far as known.

Previous place of abode.

Whether first attack.

Age (if known) on first attack.

When and where previously under care and treatment.

Duration of existing attack.

Supposed cause.

Whether subject to epilepsy.

Whether suicidal.

Whether dangerous to others.

Whether any near relative has been afflicted with insanity.

Name and Christian name and address of nearest known relative of the patient and degree of relationship if known.

I certify that to the best of my knowledge the above particulars are correct.

[To be signed by the relieving officer.]

Sect. 16.

Form 12.

Order for reception of a Pauper Lunatic or Lunatic wandering at large.

I, C.D., having called to my assistance E.F. of

, a duly qualified medical practitioner, and being satisfied that A.B. [describing him] is a pauper in receipt of relief [or in such circumstances as to require relief for his proper care and maintenance], and that the said A.B. is a lunatic [or an idiot, or a person of unsound mind] and a proper person to be taken charge of and detained under care and treatment, or that A.B. [describing him] is a lunatic, and was wandering at large, and is a proper person to be taken charge of and detained under care and treatment, hereby direct you to receive the said A.B. as a patient into your asylum [or hospital, or house]. Subjoined is a statement of particulars respecting the said A.B.

(Signed) C.D.

A justice of the peace for

Dated the

day of

one thousand eight hundred and

To the superintendent of the asylum for the county [or borough] of

[or the lunatic hospital of

; or E.F.

proprietor of the licensed house of

; describing the asylum, hospital, or house].

Note.—Where the order directs the lunatic to be received into any asylum, other than an asylum of the county or borough in which the parish or place from which the lunatic is sent is situate, or into a registered hospital or licensed house, it shall state, that the justice making the order is satisfied that there is no asylum of such county or borough, or that there is a deficiency of room in such asylum; or (as the case may be) the special circumstances, by reason whereof the lunatic cannot conveniently be taken to an asylum for such first-mentioned county or borough.

Statement of Particulars.

Statement of particulars referred to in the above or annexed order.

The following is a statement of particulars relating to the said A.B. [¹] :—

Name of patient, with Christian name at length.

Sex and age.

†Married, single, or widowed.

†Rank, profession, or previous occupation (if any).

†Religious persuasion.

Residence at or immediately previous to the date hereof.

†Whether first attack.

Age on first attack.

When and where previously under care and treatment as a lunatic, idiot, or person of unsound mind.

†Duration of existing attack.

Supposed cause.

Whether subject to epilepsy.

Whether suicidal.

Whether dangerous to others, and in what way.

Whether any near relative has been afflicted with insanity.

Union to which lunatic is chargeable.

Names, Christian names, and full postal addresses of one or more relatives of the patient.

Name of the person to whom notice of death to be sent, and full postal address if not already given.

(Signed)

G.H.

To be signed by the Relieving Officer or Overseer.

[Form 13 rep. 54 & 55 Vict. c. 65, s. 29]

Sect. 229.

Form 14.

Consent to the admission of a boarder.

We hereby sanction the admission of A.B. as a boarder into for the term of

from the

day of

in accordance with the provisions of the statute and in terms of A.B.’s application.

(Signed)

Two of the Commissioners in Lunacy.

[or Two of the justices for

.]

Dated the

day

18 .

Sect. 13.

Form 15.

Order for Reception of a Lunatic not under proper care and control, or cruelly treated or neglected, to be made by a Justice appointed under the Lunacy Act, 1890.

I, the undersigned C.D., being a Justice for

specially appointed under the Lunacy Act, 1890, having caused A.B. to be examined by two duly qualified medical practioners, and being satisfied that the said A.B. is a lunatic not under proper care and control [or is cruelly treated or neglected by the person having the care or charge of him,] and that he is a proper person to be taken charge of and detained under care and treatment, hereby direct you to receive the said A.B. as a patient into your asylum [or hospital or house]. Subjoined is a statement of particulars respecting the said A.B.

(Signed)

A justice of the peace for appointed under the above-mentioned Act.

Dated

To the Superintendent of the Asylum for

, or of the lunatic hospital of

, or the resident licensee of the licensed house at

Note.—Where the order directs the lunatic to be received into any asylum, other than an asylum of the county or borough in which the parish or place from which the lunatic is sent is situate, or into a registered hospital or licensed house, it shall state, that the justice making the order is satisfied that there is no asylum of such county or borough, or that there is a deficiency of room in such asylum; or (as the case may be) the special circumstances, by reason whereof the lunatic cannot conveniently be taken to an asylum for such first-mentioned county or borough.

Statement of Particulars.

Statement of particulars referred to in the above or annexed order.

The following is a statement of particulars relating to the said A.B. [¹] :—

Name of patient, with Christian name at length.

Sex and age.

†Married, single, or widowed.

†Rank, profession, or previous occupation (if any).

†Religious persuasion.

Residence at or immediately previous to the date hereof.

†Whether first attack.

Age on first attack.

When and where previously under care and treatment as a lunatic, idiot, or person of unsound mind.

†Duration of existing attack.

Supposed cause.

Whether subject to epilepsy.

Whether suicidal.

Whether dangerous to others, and in what way.

Whether any near relative has been afflicted with insanity.

Union to which lunatic is chargeable.

Names, Christian names, and full postal addresses of one or more relatives of the patient.

Name of the person to whom notice of death to be sent, and full postal address if not already given.

(Signed)

To be signed by the relieving officer, overseer, or other person on whose information the order is made.

Form 16.

Sect. 335.

Certificate of Disability of Person entitled to Payments from a Public Department.

I,

, being a justice of the peace for or the rector, or vicar, or minister [state the denomination and residence], hereby certify that I know the said A.B., and that I believe him or her to be unable, by reason of mental disability, to manage his or her affairs; and I further certify that I believe the family of the said A.B. to consist of

Dated

Signed [Name].

[Place of abode.]

Form 17.

Sect. 335.

Medical Certificate of Disability of Person entitled to Payments from a Public Department.

I

, being a person registered under the Medical Act, 1858, and in the actual practice of my profession, hereby certify that I have this day visited and personally examined A.B., and that the said A.B. is unable, by reason of mental disability, to manage his or her affairs, and that I have formed this conclusion on the following grounds, viz.: [state them].

Dated

Signed [Name].

[Postal address in full.]

Form 18.

Sect. 207.

Form of Licence by Commissioners for a House not previously licensed.

Know all men, that we, the Commissioners in Lunacy, do hereby certify that A.B. of

in the parish of

in the county of

has delivered to us a plan and description of a house and premises situate at

in the county of

proposed to be licensed for the reception of lunatics, and we, having considered and approved the same, do hereby authorise the said A.B. (he undertaking to reside therein) to use the said house and premises for the reception of

male [or

female, or

male and

female] lunatics, of whom not more than

shall be private patients, for

calendar months from this date.

Sealed with our common seal this

day of

18 .

Witness,

Y.Z., Secretary to the Commissioners of Lunacy.

Form 19.

Sect. 207.

Form of Licence by Justices for a House not previously licensed.

Know all men, that we, the undersigned justices of the peace, acting in and for

in general [or quarter or special] sessions assembled, do hereby certify that A.B. of

in the parish of

in the county of

has delivered to the clerk of the peace a plan and description of a house and premises, situate at

in the county of

proposed to be licensed for the reception of lunatics, and has applied to us for a licence thereof: And whereas the Commissioners in Lunacy have reported upon the said application, and their report has been received, and has been taken into consideration by us; Now we, having considered and approved the application, do hereby authorise the said A.B. (he undertaking to reside therein) to use the said house and premises for the reception of

male [or female or

male and

female] lunatics, of whom not more than

shall be private patients, for the space of

calendar months from this date.

Given under our hands and seals this

day of

18 .

Witness, Y.Z., Clerk of the Peace.

Sect. 207.

Form 20.

Licence by Commissioners or Justices for a House previously licensed.

Know all men, that we, the Commissioners in Lunacy [or we the undersigned justices of the peace for

in general (or quarter or special) sessions assembled] do hereby certify that A.B. of

in the parish of

in the county of

has delivered to us [or the clerk of the peace] a list of the number of patients now detained in a house and premises situate at

in the county of

licensed on the

day of

for the reception of lunatics, and we, having considered the same, do hereby authorise the said A.B., he undertaking to reside therein, to use the said house and premises for the reception of

male [or female or

male and

female] lunatics, of whom not more than

shall be private patients, for

calendar months from this date.

Sealed with our common seal [or given under our hands and seals], this day of

Witness,

Y.Z., Secretary to the Commissioners in Lunacy,

[or Clerk of the Peace].

Sect. 248.

Form 21.

Form of Agreement for uniting for the purpose of erecting or providing an asylum for the reception of lunatics.

It is agreed this

day of

between the visiting committees for the county of

and the borough of

[as the case may be], that the said county and borough [as the case may be], shall henceforth be united for the purposes of the Lunacy Act, 1890; and that an asylum for the reception of lunatics, with all necessary buildings, courts, yards, and outlets, shall be immediately provided and properly fitted up and accommodated for the purposes mentioned in the said Act; and that the necessary expenses attending the providing, building, fitting up, repairs, and maintenance of the said asylum shall be defrayed by the said county and borough, so united, in the following proportions, such proportions being fixed according to the probable extent of the accommodation required for the lunatics of the contracting county and borough; (that is to say,)

[as the case may be, or if the expenses are not fixed, with reference to the probable extent of the accommodation, insert instead of the last clause.]

The expenses shall be from time to time charged upon and raised by such county and borough in proportion to their respective populations as stated in the last return for the time being made of the same under the authority of Parliament.

And it is further agreed, that the committee of visitors to superintend the building, erection, and management of the said asylum shall be appointed in the following proportions; the council for the said county of

shall appoint^*

, and the council for the borough of

shall appoint^*

and the proportions in which the said committee of visitors are to be appointed as aforesaid may be from time to time varied, with the consent in writing under the hands of the greater number of visitors of the said county and borough, and with the consent of the Commissioners in Lunacy, And hereunto, we, the undersigned, being the majority of each of the committees appointed by the said councils respectively, do on behalf of the said councils set our hands and seals, this day of

Sect. 332.

Form 22.

Form of Summons.

We, the Commissioners in Lunacy [or we whose names are hereunto set and seals affixed, being two of the Commissioners in Lunacy, or visitors of

], do hereby summon you personally to appear before us at

in the parish of

in the county of

on

next the

day of

at the hour of

in the

noon of the same day, and then and there to be examined, and to testify the truth touching certain matters relating to the execution of the Lunacy Act, 1890.

Sealed with the common seal of “The Commissioners in Lunacy” [or Given under our hands and seals] this

day of

Sect. 208.

[¹] Full postal address and rank, profession, or occupation.

[²] At least twenty-one.

[³] or an idiot or person of unsound mind.

[⁴] Insert a full description of the name and locality of the asylum, hospital, or licensed house, or the full name, address, and description of the person who is to take charge of the patient as a single patient.

[⁵] Some day within 14 days before the date of the presentation of the petition.

[⁶] Here state the connection or relationship with the patient.

[¹] If any particulars are not known, the fact is to be so stated. [Where the patient is in the petition or order described as an idiot omit the particulars marked †].

[¹ Words in brackets substituted by 54 & 55 Vict. c. 65, s. 23.]

[¹] Address and description.

[²] Or an idiot or person of unsound mind.

[³] Or hospital or house or as a single patient.

[⁴] To be addressed to the medical superintendent of the asylum or hospital, or to the resident licensee of the house in which the patient is to be placed.

[¹] Or hospital or asylum or as a single patient.

[²] Or an idiot or a person of unsound mind.

[³ Some day within two days before the date of the order.

[⁴] Husband, wife, father, father-in-law, mother, mother-in-law, son, son-in-law, daughter, daughter-in-law, brother, brother-in-law, sister, sister-in-law, partner, or assistant.

[⁵] See Form 2.

[¹] Insert residence of patient.

[²] City or borough, as the case may be.

[³] Insert profession or occupation, if any.

[⁴] Insert the place of examination, giving the name of the street, with number or name of house, or should there be no number the christian and surname of occupier.

[⁵] City or borough, as the case may be.

[⁶] Omit this where only one certificate is required.

[⁷] If the same or other facts were observed previous to the time of the examination, the certifier is at liberty to subjoin them in a separate paragraph.

[⁸] The names and christian names (if known) of informants to be given, with their addresses and descriptions.

[⁹] Strike out this clause in case of a private patient whose removal is not proposed.

[¹⁰] Insert full postal address.

[¹] If any particulars are not known, the fact is to be so stated. [Where the patient is in the order described as an idiot omit the particulars marked†.]

[¹] If any particulars are not known, the fact is to be so stated. [Where the patient is in the order described as an idiot omit the particulars marked†.]

^* Insert in these blanks either the number or the proportion of visitors; and where the number of the committee of visitors is not fixed in the agreement, but only the proportions, a provision shall be made by the agreement for fixing from time to time the number of such committee.

^* Insert in these blanks either the number or the proportion of visitors; and where the number of the committee of visitors is not fixed in the agreement, but only the proportions, a provision shall be made by the agreement for fixing from time to time the number of such committee.