Mind and its disorders : a text-book for students and practitioners / by W.H.B. Stoddart.

  • W.H.B. Stoddart
Date:
1908
Catalogue details

Licence: In copyright

Credit: Mind and its disorders : a text-book for students and practitioners / by W.H.B. Stoddart. Source: Wellcome Collection.

Provider: This material has been provided by King’s College London. The original may be consulted at King’s College London.

    508/562 (page 466)
    S3 Vict., c. s, Sched. 2, Form i. Petition for an Order for Reception of a Private Patient. 5n tf3e /iftattec of- (6) Full postal ad- dress, and rank, pro- fession, or occupation. (a) a J ustice of the Peace for , or His Honour the Judge of the County Court of , or Sti- pendiary Magistrate for . a person alleged to be of unsound mind. To (a) trbe ipctmon of- of {b). in the County of_ (c) At least twenty- one. I. I am_ _(c) years of age. (d) A lunatic, or an idiot, or a person of unsound mind. of 2. I desire to obtain an Order for the Reception ^as (d) (e) Asylum, or hos- pital, or house, as the lg\ case may be. _of_ (/) Insert a full de- scription 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. (g) Some day within 14 days before the date of the presentation of the petition. (h) Here state the connection or relation- ship with the patient. situate at (/)_ 3. I last saw the said^ at_ on the (g). _day of- 19- 4. I am the (/()_ _of the said. [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. The reasons why this Petition is not presented by g, relation or connection are as follows :