Mental diseases : a text-book of psychiatry for medical students and practitioners / by R.H. Cole.

  • Cole, R. H. (Robert Henry), 1866-
Date:
1913
Catalogue details

Licence: In copyright

Credit: Mental diseases : a text-book of psychiatry for medical students and practitioners / by R.H. Cole. Source: Wellcome Collection.

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

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    3, ORDER FOR RECEPTION OF A PAUPER LUNATIC, OR LUNATIC WANDERING AT LARGE having called to my assistance, of -a duly qualified medical practitioner, and being satisfied that, of^ is a pauper in receipt of relief, [or in such cii-cumstances as to require relief for h proper care and maintenance] and that the said _ is a lunatic or a person of unsound mind and a proper person to be taken charge of and detained under care and treatment, or that 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 as a patient into your Asylum. Subjoined is a statement of particulars respecting the said ^ • (StQuet))— ^ Justice of the Peace Jor the County of) (Datet)) the -._ day of 19 _ To the Superintendent of the Asylum for the County of _ STATEMENT OF PARTICULARS REFERRED TO IN THE ABOVE ORDER 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*] The following is a Statement of Particulars relating to the said _ 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 Treat- f ment 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 f 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 j sent, and full Postal Address, if not already given \ (SiGueb) Relieving Officer of the Union 5)ateb) the day of ifl