Page images
PDF
EPUB
[ocr errors][ocr errors][merged small][merged small][merged small][merged small][merged small]

In the matter of A.B. a Lunatic (or an Insane person, or an Idiot, or a person of

unsound mind]. WE the General Board in Lunacy in Scotland, in pursuance of the provisions of an Act passed in the

year

of the reign of Her Majesty Queen Victoria, intituled, [here insert the title of this Act], do hereby grant warrant to Messengers-at-Arms and Sheriff Officers, conjunctly and severally, to summon, warn and charge and each of them, personally or at their respective dwelling-places, in common form, to appear before the said Board at [insert place], on the

o'clock

noon, and then and there to testify and bear witness, so far as they and each of them know and shall be asked concerning the aforesaid matter, under the penalties specified in the said Act. Given at Edinburgh this

in the year One thousand eight hundred and By the authority of the Board,

G. H., Secretary.

day of

18

, at

day of

SCHEDULE (B.)

[ocr errors]

FORM OF LICENSE BY THE BOARD. WE, the General Board in Lunacy in Scotland, do hereby certify that A.B. of in the parish of and county of

has delivered to us a plan and description of a house and premises proposed to be licensed for the reception of Lunatics, situated at

in the county of

in which it is proposed to receive patients not exceeding

in number, [or, in the case of a renewed license, has delivered to us a list of the number of patients now detained in a house and premises situated at

in the county of

in which there are at present

patients]; and we having considered and approved of the do hereby authorize and empower the said A.B. [he intending, or not intending, to reside therein), to use and employ the said house and premises for the reception of male (or female, or male and

female) lunatics, whereof are paupers, for the space of

calendar months from this date. Given at Edinburgh this

in the year One thousand eight hundred and By the authority of the Board,

G. H., Secretary.

same,

day of

SCHEDULE

SCHEDULE (C.)
FORM of Statement to be lodged with a PETITION to the SHERIFF for the

RECEPTION of a LUNATIC.
1. Christian name and surpame of Patient at length.
2. Sex and age.
3. Married, single or widowed.
4. Condition of life and previous occupation (if any).
5. Religious persuasion, so far as known.
6. Previous place of abode.
7. Place where found and examined.
8. Length of time insane.
9. Whether first attack.
10. Age (if known) on first attack.
11. Whether subject to epilepsy.
12. Whether suicidal, or dangerous to others.
13. Previous place of confinement (if any).
14. Special circumstances (if any) preventing the insertion of any of the above

particulars. I certify that, to the best of my knowledge, the above particulars are correctly stated. Dated this

day of One thousand eight hundred and

To be signed by the party applying.

SCHEDULE (D.)

FORM OF MEDICAL CERTIFICATE. I, the undersigned, do hereby certify, on soul and conscience, that I have this day, separately from any other medical practitioner, visited and personally examined A. B., [insert designation and residence, and if a pauper, state so], and that the said A. B. is a Lunatic [or an insane person, or an Idiot, or a person of unsound mind), and a proper person to be detained and taken care of; and that I have formed this opinion from the following fact [or facts] ; viz. [here state them).

(signed) [Name and Medical Designation and Place of Abode.]

[blocks in formation]

FORM of Order to be granted by the SHERIFF for the RECEPTION of a Lunatic.

I, C. D., Sheriff [or Sheriff Substitute, or Steward, or Steward Substitute) of the County [or Stewartry] of

having had produced to me, with a petition at the instance of G. H. [name and designation] certificates under the hands of

and being two medical persons duly qualified in terms of an Act, [specify this Act], setting forth that they had separately visited and examined A. B., [describe him, and if a pauper, state so], and that the said A. B. is a lunatic (or an insane person, or an idiot, or a person of unsound mind), and a proper person to be detained and taken care of, do hereby authorize you to receive the said A. B., as a Patient into the public (or private] Asylum of

; and I authorize his transmission to the said Asylum accordingly, and I transmit to you herewith the said medical certificates, and a statement regarding the said A. B., which accompanied the said petition. Dated this

18

(signed) C. D. To the Superintendent of the Public Asylum for Private Asylum) of

[Designation.)

day of

450.

E 2

SCHEDULE

SCHEDULE (F.)

NOTICE OF ADMISSION.

day of

I HEREBY give notice, That A. B. [describe him] was received into this house as a private (or pauper) patient, on the

, and I hereby transmit a copy of the Order and Medical Certificates and Statement on which he was received.

Subjoined is a Report with respect to the mental and bodily condition of the abovenamed patient.

(signed) E. F. Superintendent. Dated at this

One thousand eight hundred and

day of

REPORT.

I have this day seen, and personally examined, A. B. the patient named in the above notice, and hereby report and certify, with respect to his mental state, that [insert particulars], and with respect to his bodily health and condition that [insert particulars].

(signed) J. K. Physician (or Surgeon.]

One thousand eight hundred and

Dated this

day of

SCHEDULE (G.)

I, A. B., a medical person duly qualified in terms of the Act [specify this Act], certify, on soul and conscience, that C. D. [name and design the patient], is afflicted [state the nature of the disease], but that the malady is not confirmed, and that I consider it expedient, with a view to his recovery, that he should be placed [specify the house in which the patient is to be kept], for a temporary residence of specify a time, not exceeding six months].

SCHEDULE (H.)

DISTRICTS OR DIVISIONS OF SCOTLAND. 1.-THE EDINBURGH DISTRICT

Comprising the Counties of Edinburgh, Linlithgow, Haddington, Berwick, Rox

burgh, Selkirk, Peebles, and Orkney. 2.-THE INVERNESS DISTRICT

Comprising the Counties of Inverness, Sutherland, Ross Cromarty, Elgin, Nairn

and Banff. 3.-THE ABERDEEN DISTRICT

Comprising the Counties of Aberdeen, Caithness, Kincardine and Shetland. 4.-THE PERTH DISTRICT

Comprising the Counties of Perth, Forfar, Fife, Kinross and Clackmannan. 5.-THE DUMFRIES DISTRICT

Comprising the Counties of Dumfries, Ayr and Wigtown, and the Stewartry of

Kirkcudbright. 6.- THE GLASGOW DISTRICT

Comprising the County of Lanark. 7.-The RENFREW DISTRICT

Comprising the Counties of Renfrew, Stirling, Dumbarton, Argyle and Bute.

[merged small][ocr errors]
[merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][ocr errors][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][ocr errors][merged small][merged small][merged small]
[merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][ocr errors][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small][merged small]
« EelmineJätka »