SCHEDULES

TO WHICH THE FOREGOING ACT REFERS.

SCHEDULE (A.)

FORM OF SUMMONS BY THE BOARD.

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 day of

18

at

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.

FORM OF LICENSE BY THE BOARD.

WE, the General Board in Lunacy in Scotland, do hereby certify that A.B. of

has delivered to us a plan and premises proposed to be licensed for the reception of in which it is proin number, [or, in the case of a

in the county of

posed to receive patients not exceeding renewed license, has delivered to us a list of the number of patients now detained in a house and premises situated at in which there are at present patients]; and we having considered and approved of the same, 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 are paupers, for the space of Given at Edinburgh this

day of

female] lunatics, whereof calendar months from this date. in the year One thousand

eight hundred and

By the authority of the Board,

G. H., Secretary.

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 surname 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 círcumstances (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].

[Name and Medical Designation and Place of Abode.]

(signed)

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 ; and I authorize his transmission to the said Asylum accordingly, and

of

I transmit to you herewith the said medical certificates, and a statement regarding the said A. B., which accompanied the said petition.

Dated this

day of

To the Superintendent of the Public Asylum [or Private Asylum] of

18

(signed) C. D.

[Designation.]

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. One thousand eight hundred and

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)

Dated this

day of

J. K. Physician [or Surgeon.] One thousand eight hundred and

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, Roxburgh, 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.

SCHEDULE