FORM V11
Rule-25 of Central Mental Authority 1990,The Mental Health Act 1987
Application for reception order
(By Medical officer in charge of a psychiatric hospital)



From

Dr-------------------------------


To

The Magistrate,
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Sir,

 Sub: Reception order for ----------------------------son/daughter of ---------------------------------------


I, Dr------------------------------- maintain psychiatric hospital/nursing home at ---------------------------under

licence No----------------------- dated-----------------------------

I request you to issue reception order in respect of Sh. / Smt.-------------------------------------------------------
son / daughter of --------------------------------------- who is being treated at my hospital as a involuntary patient
and is not willing to continue. He/she has the following symptoms & signs.

1.

2.

3.

He/She requires to be in the hospital for treatment / personal safety / other protection.

Thanking you,
                                                                                                                      Yours sincerely

Place:                                                                             Signature-------------------------------------------

Date:                                                                              Name-----------------------------------------------