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    Form - I Staff Pattern

    Uploaded by

    Bonnie Bennet
    This document contains two application forms for establishing or maintaining a psychiatric hospital or nursing home. The forms request information such as the applicant's name and qualifications, address of the proposed facility, available accommodations and facilities, and staffing details. The applicant undertakes to abide by rules and regulations and requests a license to establish or maintain the psychiatric facility.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Form - I Staff Pattern

    Uploaded by

    Bonnie Bennet
    118 views2 pages
    This document contains two application forms for establishing or maintaining a psychiatric hospital or nursing home. The forms request information such as the applicant's name and qualifications, address of the proposed facility, available accommodations and facilities, and staffing details. The applicant undertakes to abide by rules and regulations and requests a license to establish or maintain the psychiatric facility.

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    Application form

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    This document contains two application forms for establishing or maintaining a psychiatric hospital or nursing home. The forms request information such as the applicant's name and qualifications, address of the proposed facility, available accommodations and facilities, and staffing details. The applicant undertakes to abide by rules and regulations and requests a license to establish or maintain the psychiatric facility.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    118 views2 pages

    Form - I Staff Pattern

    Uploaded by

    Bonnie Bennet
    This document contains two application forms for establishing or maintaining a psychiatric hospital or nursing home. The forms request information such as the applicant's name and qualifications, address of the proposed facility, available accommodations and facilities, and staffing details. The applicant undertakes to abide by rules and regulations and requests a license to establish or maintain the psychiatric facility.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Application form h.

    Investigation and laboratory facilities


    Form - I i. Treatment Facility
    (See rule 15 of State Mental Health Rules, 1990) Staff Pattern:
    Application for maintaining a Psychiatric Hospital / Nursing Home a. Number of doctors:
    b. Number of Nurses:
    To c. Number of Attenders:
    The Licensing Authority, d. Others:
    Govt. Institute of Mental Health, I am sending herewith a bank draft for Rs--------------- drawn in
    Medavakkam Tank Road, favour of Director, Institute of Mental Health, Kilpauk, Chennai as
    Kilpauk, Chennai - 600 010. licensing fee.
    I hereby undertake to abide by the rules and regulation of the Mental
    Dear Sir, Health Authority. 
    I/We intend to establish / maintain a Psychiatric Hospital / I request you to consider my application and grant the license for
    Psychiatric Nursing Home in respect of which I am/we are holding a establishment / maintenance of Psychiatric Hospital / Nursing
    valid license for the establishment / maintaining of such hospital / Home.
    nursing home. The details of the hospital / nursing home are given
    below:
    1. Name of Applicant: Yours faithfully,
    2. Details of license with reference to the name of the Authority
    issuing the license and date:
    3. Age: Signature:
    4. Professional experience in Psychiatry: Date:
    5. Permanent address of the applicant: Name:
    6. Location of the proposed Hospital / Nursing Home:
    7. Address of the proposed Hospital / Nursing Home:
    8. Proposed accommodation:
    a. Number of rooms
    b. Number beds
    Facilities provided:
    a. Out-patient facility
    b. Emergency services
    c. Inpatients facilities
    d. Occupational and recreational facilities
    e. ECT facilities
    f. X-ray facilities
    g. Psychological testing facilities 
    Form – II Staff Pattern:
    (See rule 15, State Mental Health Rules) a. Number of Doctors
    Application for establishment of a Psychiatric Hospital / Nursing b. Number of Nurses
    Home under sub-section (2) of Section 7 of Mental Health Act, 1987 c. Number of Attenders
    d. Others
    To I am sending herewith a bank demand draft for Rs. ___________
    The Licensing Authority, drawn in favour of Director, Institute of Mental Health, Kilpauk,
    Govt. Institute of Mental Health, Chennai as licensing fee.
    Kilpauk, Chennai - 600 010. I hereby undertake to abide by the rules and regulation of the Mental
    Health Authority. I request you to consider my application and grant
    Dear Sir, the license.
    I/We intend to establish / maintain a Psychiatric Hospital / Yours faithfully,
    Psychiatric Nursing Home at (mention the place) I am
    herewith giving you the details. Signature:
    1. Name of Applicant: Date:
    2. Qualification of Medical Officer to be in charge of Nursing Name:
    Home/ Hospital (Certificate to be attached):
    3. Age:
    4. Professional experience in Psychiatry:
    5. Permanent address of the applicant:
    6. Location of the proposed Hospital / Nursing Home:
    7. Address of the proposal Hospital / Nursing Home:
    8. Proposed accommodation:
    a. Number of rooms
    b. Number beds
    Facilities provided:
    a. Out-patient facility
    b. Emergency services
    c. Inpatients facilities
    d. Occupational and recreational facilities
    e. ECT facilities
    f. X-ray facilities
    g. Psychological testing facilities 
    h. Investigation and laboratory facilities
    i. Treatment Facility

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