CHIEF CIVIL PSYCHIATRIST APPROVED FORM 2A	
	
               DECISION MAKING
           CAPACITY- 
             ADULTS

Mental Health Act 2013
Section 7

THCI: (PatientId): 	

Family Name:  <PtSurname>	

Given Name: <PtFirstName>	

DOB: <PtDoB>  Gender: <PtSex>	

Address: <PtAddress>	

Phone: <PtPhoneH>  Mob: <PtPhoneMob>	

AFFIX STICKER HERE	
RECORD OF DETERMINATION - DECISION MAKING CAPACITY - ADULTS	
                TREATING MEDICAL PRACTITIONER TO COMPLETE
	The patient or prospective patient is the person who is being assessed for capacity.	
Patient or prospective patient's name:

<PtName>	

Treating medical practitioner's name:

<DrName>	

For the purposes of the Mental Health Act 2013, an adult is taken to have the capacity to make a decision about his or her ownassessment or treatment unless a person or body considering that capacity under the Act is satisfied that the he or she is unable to make a decision because of an impairment of, or disturbance in, the functioning of the mind or brain, and he or she is unable to understand:
·	Information relevant to the
decision, or
·	Retain information relevant to the decision, or
·	Use or weigh information relevant to the decision, or
·	Communicate the decision             (whether by  gesture,                      speech or other means).

An adult may be taken to understand information relevant to a decision if it reasonably appears that he or she is able to understand an explanation of the nature and consequences of the decision given in a way that is appropriate to his or her circumstances (whether by words, signs or other means).

An adult may be taken to be able to retain information relevant to a decision even if he or she may onlybe able to retain the information briefly.

Information relevant to a decision includes information on the consequences of making the decision one way or the other, deferring the making of the decision, and failing to make the decision.    	
I am Satisfied that the patient named above does not have the capacity to make a decision, under the Mental Health Act 2013, about his or her own: 
               q     Assessment    OR    q Treatment 
Specifically, I confirm that the patient named above: 
q   Is unable to make the decision because of an impairment of, or disturbance in, the functioning of the mind or brain AND
 
q   Is unable to understand information relevant to the decision OR

q   Is unable to retain information relevant to the decision OR

q   Is unable to use or weigh information relevant to the decision OR

q   Is unable to communicate the decision (whether by gesture, speech or other means)

Reasons for determination  that the patient named above does not have the capacity to make a decision about his or her own assessment or treatment: 

	

Steps that have been taken to assist the patient named above to make a decision about his or her own assessment or treatment: 

	

Treating medical practitioner's signature:_____________________________________

Date and time of determination:    <TodaysDate>  Time: <CurrentTime>	

COPY TO: q  LOC OTHER:q If record is about the capacity to make a decision about assessment – append to AO                                                                                       q If record is about the capacity to make a decision about treatment – append to TO