Mental Health and Wellbeing Act 2022 forms

The department has developed the following forms to support the implementation of the Mental Health and Wellbeing Act 2022 (the Act). .

Services can download and print forms from the website or order hard copies of selected forms from Allanby Press Printers.

The MHWA125 notice of death form is available on the Chief Psychiatrist’s website.

Assessment Order forms

MHWA 101 Assessment Order

pdf 1.83 MB

MHWA 102 Receipt of person subject to Inpatient Assessment Order

pdf 830.19 KB

MHWA 103 Variation of Assessment Order

pdf 1.63 MB

MHWA 104 Extension of Assessment Order

pdf 1.75 MB

MHWA 105 Revocation of Assessment Order

pdf 1.21 MB

MHWA 106 Variation of Court Assessment Order

pdf 1.28 MB

Temporary Treatment Order and Treatment Order forms

MHWA 110 Temporary Treatment Order

pdf 1.94 MB

MHWA 111 Variation of Temporary Treatment Order or Treatment Order

pdf 2 MB

MHWA 112 Revocation of Temporary Treatment Order or Treatment Order

pdf 1.85 MB

MHWA 113 Application for another Treatment Order

pdf 1.77 MB

MHWA 114 Application to Mental Health Tribunal

pdf 1.55 MB

Operational forms (leave, transfer etc)

MHWA 120 Leave of absence for compulsory patient

pdf 1.71 MB

MHWA 122 Revocation of leave of absence for compulsory patient

pdf 1.41 MB

MHWA 123 Variation of order to transfer compulsory patient

pdf 2.24 MB

MHWA 124 Taking care and control of patient absent without leave

pdf 1.54 MB

Treatment, applications and consent

MHWA 130 Substitute consent to medical treatment by authorised psychiatrist

pdf 1.88 MB

MHWA 131 Informed consent to ECT

pdf 1.77 MB

MHWA 131A Informed consent to ECT by medical treatment decision maker

pdf 2.41 MB

MHWA 132 Application for electroconvulsive treatment (ECT)

pdf 1.96 MB

MHWA 132A Application for ECT - Voluntary Adult without capacity to consent

pdf 1.33 MB

Restrictive interventions

MHWA 140 Authority for use of restrictive interventions

pdf 2.7 MB

MHWA 141 Authority for urgent physical restraint

pdf 2.45 MB

MHWA 142 Restrictive interventions observations

pdf 1.13 MB

MHWA 143 Authority for use of chemical restraint

pdf 2.98 MB

Guidelines regarding the use of chemical restraint are published by the Office of the Chief Psychiatrist.

Security and forensic patients

MHWA 150 Receipt of security or forensic patient

pdf 888.56 KB

MHWA 151 Leave of absence for security patient

pdf 1.71 MB

MHWA 153 Revocation of leave of absence for security patient

pdf 1.63 MB

MHWA 154 Special leave of absence for forensic patient

pdf 838.61 KB

MHWA 155 Application for monitored leave for security patient

pdf 1.33 MB

MHWA 156 Transfer of security or forensic patient

pdf 1.61 MB

MHWA 157 Discharge of security patient

pdf 1.71 MB

MHWA 158 Report of psychiatrist

pdf 1.59 MB

MHWA 159 Report of authorised psychiatrist

pdf 1.55 MB

Cross border

MHWA 170 Interstate transfer of compulsory patient with consent

pdf 832.31 KB

MHWA 171 Interstate transfer of compulsory patient without consent

pdf 898.97 KB

Admissions, registration and separations

MHWA PR 1 Registration - Demographics

pdf 1.02 MB

MHWA PR 1a Registration - Legal and clinical

pdf 866.05 KB

MHWA PR 2 Admission

pdf 961.71 KB

MHWA PR 5 Separation

pdf 891.24 KB

Advance statement of preferences

Forms for making or revoking an advance statement of preferences are on the advance statement of preferences page.

Nominated support persons

Forms for nominating a nominated support person or revoking a nomination can be found on the nominated support persons page.

Access to archived mental health information

Access to archived mental health information held by the Department of Health can be requested through Freedom of Information or via email at foi@health.vic.gov.au