Frequently Asked Questions

• Procedure to commence involuntary treatment
• Involuntary treatment orders (ITO)
• Treatment plans
• Community treatment orders (CTO)
• Legislation
• CMI users
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The information provided in response to these frequently asked questions is intended as general information and not as legal advice. If individuals or health service providers have queries about individual cases or their obligations under the Victorian Mental Health Act 1986, they should obtain independent legal advice.

FAQ - Procedure to commence involuntary treatment

Q1. What documentation is required to commence involuntary treatment?

A. Two documents must be completed:

• A Request is completed by any person over the age of 18 years.
• A Recommendation is completed by a registered medical practitioner.

Q2. Can the same person complete the Request and Recommendation?

A. No. Different people must make the Request and Recommendation.
In addition, the registered medical practitioner making the Recommendation cannot be a relative or guardian of the person being recommended.

Q3. Does it matter which is completed first, the Recommendation or the Request?

A. No, but both must be completed before any further action can be taken.

Q4. What happens when the Request and Recommendation have been made?

A. A Request and Recommendation are sufficient authority to:

• Take the person to an approved mental health service, where an Involuntary Treatment Order will be made; or
• Arrange for a registered medical practitioner employed by an approved mental health service or a mental health practitioner to assess the person.

Q5. Who can take the person to an approved mental health service or arrange the assessment?

A. The following people can take the recommended person to an approved mental health service or arrange the assessment:

• The person who made the Request.
• A person authorised by the person who made the Request.
• A 'prescribed person'. This means a member of the police force, an ambulance officer or member of the following categories of health professionals:
  • Registered medical practitioners
  • Registered medical practitioners
  • Registered nurses
  • Registered psychologists
  • Social workers
  • Occupational therapists-
    -employed, appointed or engaged to provide care and treatment to persons with a mental disorder in an approved mental health service, a child and adolescent psychiatry service, a premises licensed under section 75 of the Act, a hospital admitting or caring for persons with a mental disorder, a mental health service of a community health centre, a psychiatric outpatient clinic or a community mental health service.

Q6. Can a non-emergency patient transport (NEPT) provider take a recommended person to an approved mental health service?

A. No.

NEPT providers should not provide transport where that transport is being authorised by a provision in the Mental Health Act.

If clinical transport is required to take a recommended person to an approved mental health service, a public ambulance service provider should provide that transport in an ambulance. Importantly, ambulance paramedics employed by public ambulance service providers are 'prescribed persons' under the Mental Health Act and, as such, have necessary powers to ensure a person can be safely transported to an approved mental health service.

See also: Non-emergency patient transport of people with mental illness.

Q7. How long does an Authority to Transport (Schedule 3) last?

The Mental Health Act does not specify a period for an Authority to Transport to have effect. However, an Authority to Transport should only ever be completed in urgent situations. Under section 9A(1)(b) of the Act, a 'mental health practitioner' must be satisfied that the criteria in section 8(1) of the Mental Health Act apply to the person and as a result the person requires immediate treatment (section 8(1)(b)). Further, the circumstances must be so urgent that it is not reasonable to wait for the attendance of a medical practitioner (section 9A(1)(a)).

In this context, the Chief Psychiatrist recommends that the authority should be implemented as soon as practicable, but in any case no longer than 24 hours. Any delay should only be to make the necessary arrangements for transport.

In some circumstances it may not be possible to transport the person within these timelines, for example if the person absconds after the authority is made. If the person is located after more than 24 hours and is still assessed as requiring involuntary treatment, procedures for initiating involuntary treatment under the Mental Health Act should be commenced again.

If an Authority to Transport lapses in this way, the form should be included in the person's clinical record with an explanation of the circumstances.

Q8. If a registered medical practitioner employed by an approved mental health service or a mental health practitioner is asked to assess a recommended person, what decision do they need to make?

A. The practitioner must either:

• take the person, or arrange for the person to be taken, to an appropriate approved mental health service where an Involuntary Treatment Order will be made; or
• make an Involuntary Treatment Order for the person.
  The practitioner must consider the criteria in section 8(1) of the Act in deciding what action to take [see section 12(2) & (3)]. For example, the practitioner might make an ITO if he/she believes that the person would be suitable to receive treatment in the community on a community treatment order.

Q9. If a practitioner has been asked to assess a recommended person, how quickly should they see the person?

A. The practitioner should see the person and make a decision as soon as practicable [see section 12(2)].

Q10. How long do the Request and Recommendation last?

A. The life of the Request and Recommendation is up to 72 hours from the date and time the recommending registered medical practitioner examined the person.
Even though the Act allows this period up to 72 hours, action to have the person taken to an approved mental health service or assessed by a registered medical practitioner or a mental health practitioner should commence as soon as practicable (see Q4. above).
Once an Involuntary Treatment Order is made, the Request and Recommendation cease to have effect (effectively becoming historical documents) and the 72-hour period associated with the Request and Recommendation ends.

Q11. What is the documentation if a voluntary inpatient needs involuntary treatment?

A. The documentation is the same. A Request and Recommendation should be completed [see section 9].
If the person is already an inpatient and therefore already in the approved mental health service, the medical practitioner employed by the approved mental health service who completes the Recommendation should also complete an Involuntary Treatment Order.

FAQ - Involuntary treatment orders (ITO)

Q1. What is the purpose of an ITO?

A. An ITO is a legal document and is the basis for involuntary treatment while a person remains an involuntary patient. It replaces the old concept in the Mental Health Act of 'admission and detention'. When an ITO is made, the person becomes an involuntary patient of the relevant approved mental health service.
The ITO also establishes the point in time when the 24-hour clock starts ticking for the examination by the authorised psychiatrist under section 12AC.

Q2. Who completes the ITO?

A. A registered medical practitioner employed by an approved mental health service or a mental health practitioner completes an ITO.

Q3. If a mental health practitioner has completed the Request, can they also complete an ITO?

A. Yes.

Q4. If a medical practitioner has completed the Recommendation, can they also complete an ITO?

A. Yes, but only if the doctor is employed by an approved mental health service.
If the Recommendation has been completed by a medical practitioner who is not an employee of the approved mental health, for example a general practitioner, the ITO will need to be completed by a different practitioner employed by the approved mental health service.

Q5. Is any medical practitioner working in a public hospital able to complete an ITO?

A. All public hospitals that have an acute psychiatric unit on campus are proclaimed to be an 'approved mental health service' under section 94 of the Act.
Where a public hospital is proclaimed as an approved mental health service, any medical practitioner employed by the public hospital (including in the emergency department) who is giving treatment or care to a patient is taken to be employed by the approved mental health service and therefore able to complete an ITO [see sections 12(2) and 12AA(2)].

Q6. Does an ITO need to be completed as soon as the recommended person arrives at the approved mental health service?

A. If a person subject to a Request and Recommendation is taken to an approved mental health service (including an emergency department that is part of a proclaimed public hospital) or is recommended in the approved mental health service, a registered medical practitioner employed by the approved mental health service or a mental health practitioner must make an involuntary treatment order for the person [see section 12AA(2)].
The Act does not specify a period of time before which the ITO should be made, but good clinical practice demands that the ITO be made as soon as practicable so that treatment can begin and there is no delay in commencing the 24-hour clock for the statutory review by the authorised psychiatrist.

Q7. Does an ITO need to be completed in circumstances where a person subject to a Request and Recommendation is taken to one approved mental health service prior to being taken to another approved mental health service?

A. If the recommended person is in short-term transit to another approved mental health service, it is not necessary to make an ITO at that service. The receiving approved mental health service will make the ITO.
However, clinical judgement and commonsense must be applied. If the person is held at the transit approved mental health service for anything more than a short period, it is expected that a medical practitioner or a mental health practitioner at that service should complete the ITO. This ensures treatment can commence and there is no delay in commencing the 24-hour clock for the statutory review by the authorised psychiatrist.
Note that if an ITO is completed at the transit approved mental health service, the person becomes a patient of that service and a formal transfer under section 39 of the Act will be necessary when the person is eventually transported to the second receiving service. Consideration will need to be given as to whether the 24-hour examination by the authorised psychiatrist is undertaken at the first approved mental health service or the receiving approved mental health service. This judgement should have regard to the amount of time remaining before the 24-hour examination is due.

Q8. Can a non-emergency patient transport (NEPT) provider take a recommended person from one approved mental health service to another approved mental health service (see question 7 above about patients in short-term transit)?

A. No.

Division 5 of the Non-Emergency Patient Transport Regulations 2005 governs the transport of people with a mental disorder from one health service to another. It specifically prohibits the transport of any person under a provision of the Mental Health Act.

This means if a person subject to a Request and Recommendation is taken to an approved mental health service (including an emergency department that is part of a proclaimed public hospital) or is recommended in the approved mental health service, and it is proposed to transfer the person to another approved mental health without admitting the person, transport must be provided by a public ambulance service provider, not a NEPT provider.

Note this prohibition only applies to transport that is being specifically authorised by the Mental Health Act. If the recommended person is placed on an involuntary treatment order at the transit approved mental health service, transport can then be provided by either a public ambulance service or a NEPT provider. The reason is that although transfers of people on involuntary treatment orders are governed by s. 39 of the Mental Health Act, the actual transport arrangements are not specified in that Act.

See also: Non-emergency patient transport of people with mental illness.

Q9. Can a person on an ITO be detained in the approved mental health service?

A. Yes. If an ITO is made at an approved mental health service, the person may be detained in the service.
However, a registered medical practitioner employed by the approved mental health service or a mental health practitioner may release the person from detention to await the examination by the authorised psychiatrist (the statutory 'within 24-hours' review) if the practitioner has:

• considered the criteria in section 8(1) of the Mental Health Act; and
• consulted with the authorised psychiatrist [see section 12AA(5)].

Q10. Where does the practitioner who releases a patient from detention write their decision, as there is no space on the ITO form for this?

A. The practitioner records his/her clinical decision in the clinical record. The record should include the reasons for the decision, identify the person's mental health needs and any risk factors that need to be addressed, specify what will be done to address each identified need and risk factor, and document the outcome of the consultation with the authorised psychiatrist and the discussion with the patient and/or their carers about their legal status, their obligations and the action to take in the event of a relapse or crisis.

Q11. What happens if the medical practitioner / mental health practitioner completing the ITO does not believe the section 8 criteria apply to the person?

A. The practitioner completing the ITO should inform the authorised psychiatrist as soon as practicable with a view to bringing forward the 24-hour examination by the authorised psychiatrist [see sections 12(5) & 12AA(6)].

Q12. Can a person be given psychiatric treatment before the 24-hour examination by the authorised psychiatrist?

A. If the person requires any psychiatric treatment immediately and the person is unable to consent to that treatment and it would not be in the best interests of the person to await the examination by the authorised psychiatrist, a medical practitioner employed by the approved mental health service can consent to the treatment on behalf of the person (see section 12AB for details).

Q13. If an ITO has been made in the community, can a general practitioner or other medical practitioner prescribe immediate treatment before the 24-hour examination by the authorised psychiatrist?

A. No, only a registered medical practitioner employed by the approved mental health service may consent to, and prescribe, immediate treatment.

Q14. Can a person be given non-psychiatric treatment (medical treatment) before the 24-hour examination by the authorised psychiatrist?

Yes, in some circumstances. The consent of the person should be obtained wherever possible. If a patient is incapable of giving consent, a medical treatment agent, a guardian or an enduring guardian (if any has been appointed) may give proxy consent. Note that the requirements for patients aged under 18 years are different [see section 85].
No consent is necessary if the medical treatment is necessary as a matter of urgency:

• To save the patient's life.
• To prevent serious damage to the patient's health.
• To prevent the patient from suffering or continuing to suffer significant pain or distress.

Q15. If a person has been made subject to an ITO in the community and their mental state deteriorates, can they be transported to the approved mental health service for admission or does a new ITO need to be made?

A. If circumstances change, at any time before the examination by the authorised psychiatrist, a registered medical practitioner employed by an approved mental health service or a mental health practitioner may take, or arrange for the person to be taken, to the approved mental health service if he/she thinks it is necessary [see section 12(6)]. It doesn't need to be the same practitioner who made the ITO. The practitioner should complete a Transport of Person subject to Involuntary Treatment Order to an Approved Mental Health Service (MHA 2).
The practitioner can take the person to the approved mental health service if it is appropriate and safe. Otherwise the practitioner can arrange for a 'prescribed person' to transport the person. A 'prescribed person' is a member of the police force, an ambulance officer or member of the following categories of health professionals:

• Registered medical practitioners
• Registered medical practitioners
• Registered nurses
• Registered psychologists
• Social workers
• Occupational therapists-

Q16. What is the next legal step after an ITO has been made?

A. The authorised psychiatrist of the approved mental health service must examine the person within 24 hours of the ITO being made to either confirm the order or to discharge the person [see section 12AC].

Q17. What happens if the authorised psychiatrist does not examine a person subject to an ITO within 24 hours?

A. All reasonable steps should be taken to ensure the authorised psychiatrist does examine a person subject to an ITO within 24 hours. If a practitioner makes an ITO in the community, part of the decision-making process should be to consider how and where the authorised psychiatrist will conduct the examination.
If the authorised psychiatrist does not examine the person within 24 hours, the person's legal status becomes unclear. In these circumstances a new Request and Recommendation should be completed.

Q18. If a patient subject to an ITO absconds before the examination by the authorised psychiatrist, is the 72-hour life of the Request and Recommendation still valid?

A. No. Once an ITO is made, the 24-hour clock for the authorised psychiatrist to examine the person commences. The effective life of the Request and Recommendation, which is up to 72 hours from the time of the examination by the recommending medical practitioner, ends when the ITO is made.
If the person is not returned in sufficient time for the authorised psychiatrist to examine the person within 24 hours, a new Request and Recommendation should be completed when the person is returned.

Q19. If the examination by the authorised psychiatrist takes place in the community, can the person be taken to and detained in the approved mental health service if necessary?

A. Yes. If the examination by the authorised psychiatrist takes place in the community and the authorised psychiatrist considers that the treatment the person requires can only be provided in the approved mental health service, the authorised psychiatrist can take, or arrange for the person to be taken, to the approved mental health service [see section 12AC(4)].
The authorised psychiatrist should complete a Transport of Person Subject to Involuntary Treatment Order to an Approved Mental Health Service (MHA 2). Transport can be provided by the authorised psychiatrist or a 'prescribed person'. The powers for taking the person to the approved mental health service are set out in section 9B of the Act.

Q20. Does the authorised psychiatrist need to 'personally' examine a person subject to an ITO at the 24-hour review?

A. The authorised psychiatrist must conduct a personal, face-to-face examination of a person subject to an ITO at the 24 hour review. The use of video-conferencing, telephone or other communication devices for this review is not permitted.

Q21. Can the authorised psychiatrist complete the ITO and conduct the statutory review?

A. Yes, if the ITO has not already been completed when the authorised psychiatrist conducts the 24-hour examination. The ITO must be completed first, because the purpose of the statutory review is to either confirm the ITO or discharge the person.

Q22. Can a patient who has been put on an ITO appeal against their involuntary status?

A. Yes. The ITO marks the commencement of involuntary status. A patient can appeal to the Mental Health Review Board at any time against being an involuntary patient [section 29]

Q23. Can a non-emergency patient transport (NEPT) provider transport an involuntary inpatient from one approved mental health service to another approved mental health service?

Yes.

Division 5 of the Non-Emergency Patient Transport Regulations 2005 governs the transport of people with a mental disorder from one health service to another. It specifically provides for the transport of involuntary patients from a health service to another health service if the requirements of Division 5 are met. Note NEPT transport can only be used where the patient has been assessed as stable and suitable for transport and only in instances where restraint is not required.

Note also that public ambulance service providers can also transport patients between health services.

See also: Non-emergency patient transport of people with mental illness.

FAQ - Treatment plans

Q1. Who must have a treatment plan?

A. All patients under the Victorian Mental Health Act 1986 must have a treatment plan [section 19A(1)]. This means all involuntary, security and forensic patients under the Act.

Q2. What is the purpose of treatment plans?

A. The purpose of treatment plans is to improve communication between the treating team and the patient. The treatment plan is intended to provide a brief clear statement about the treatment and services to be provided to the patient and to establish mutual expectations.

Q3. Who is responsible for preparing the treatment plan?

A. Section 19A(1) of the Act provides that the authorised psychiatrist must prepare, review on a regular basis and revise as required a treatment plan for each patient.
This should generally be aligned with existing clinical review processes that the authorised psychiatrist participates in to reduce duplication of effort. Service providers will need to establish processes to ensure that this happens both in the inpatient and community settings.
This obligation should not detract from the teamwork that contributes to patient care. The case manager and other members of the treating team will continue to discuss treatment with the patient, elicit their preferences and concerns and contribute to the development of the treatment plan. The authorised psychiatrist must authorise the plan.

Q4. Who is responsible for discussing the treatment plan with the patient?

A. The authorised psychiatrist is responsible to ensure that each patient is given a copy of their treatment plan and the information discussed.

The plan can be given to the patient and discussed by the authorised psychiatrist, a registered medical practitioner, the patient's case manager or any member of the following class of prescribed health professionals-

(a) either-

1. registered nurses; or
2. psychologists registered under section 6 of the Psychologists Registration Act 2000; or
3. social workers; or
4. occupational therapists; and

Q5. What are the timelines for preparing and reviewing treatment plans?

A. The Mental Health Act does not specify timelines for making or reviewing treatment plans, although it states that a plan should be reviewed on a regular basis.
Given that the purpose of a treatment plan is to improve communication between the treating team and the patient, a treatment plan should be prepared at the earliest time practicable following an admission or the confirmation of an Involuntary Treatment Order.
A treatment plan should generally be prepared at the same time a community treatment order (CTO) is made. At this time, the plan will be fairly simple and may only include sufficient information to enable the patient to engage in treatment with a community-based service. Later, the community treating team will develop a more comprehensive plan in collaboration with the patient and family/carers.
A treatment plan should be reviewed as often as clinically indicated. Where reasonably practicable, the review of treatment plans should be aligned to existing clinical practice for efficiency purposes, for example, the review of the treatment plan of a person on a CTO might be made concurrently with the 'Outcome Measurement' review. Mental health service providers should take into account the requirements of the National Standards for Mental Health Services, Commonwealth of Australia, December 1996 in setting review periods.
AMHS are expected to develop procedures and clinical practice that take into account these issues and reflect the broader policy and legislative requirements.

Q6. What information should go in the treatment plan?

A. A treatment plan must contain an outline of the treatment the patient is to receive [section 19A(3)]. It should be a brief, clear statement of the treatment to be provided by an area mental health service (AMHS).
It should be based on a current assessment of the patient's priority needs. A treatment plan should specify what the AMHS will do to address each identified need, state who is responsible for each identified action and the expected outcomes. The treatment objectives for each identified need must be realistic, focused on recovery and achievable within the expected timeframe of the plan.
Where nominated family members or carers have an agreed role, this should be specified in the plan. Similarly, if other service providers such as general practitioners and Psychiatric Disability Rehabilitation and Support Services (PDRSS) have an agreed role, this should be specified.
A plan may contain anything else the authorised psychiatrist thinks appropriate [section 19A(5)].

Q7. What is the relationship between the treatment plan and the Individual Service Plan (ISP)?

Q8. Who should be given a copy of the treatment plan?

A. The patient must be given a copy of the plan [section 19A(6)].
Subject to the requirements of section 120A of the Act, where nominated family members or carers and other service providers have an agreed role, they should be provided with a copy of the plan.

Q9. Where should the treatment plan be filed?

A. The treatment plan is a clinical document and should generally be filed in the patient's clinical record.

Q10. Does the treatment plan need to be sent with the other legal forms if a patient is transferred?

A. The treatment plan does not need to be sent with the other 'warrant' documents.
However, a copy should be forwarded to the receiving treating team to enable continuing treatment, consistent with good discharge planning practice [see section 39(3)].

Q11. What if the patient does not speak English - will there be printed plans available in other languages?

A. The purpose of treatment plans is to communicate what a service and treating team plan to do for an individual patient. Printed proforma plans will not meet this purpose as they are by necessity generic. Further most clinicians will not have multiple language skills.
Therefore, an interpreter should be used to assist with communication, as is currently the practice during assessment and admission. The interpreter will be able to translate the plan and perhaps make notes on the plan for the patient and carer in their primary language.

Q12. Is there a confidentiality issue if a patient leaves their treatment plan lying around for others to see?

A. Mental health service providers will need to develop guidelines for ensuring patients receive a copy of their treatment plan in a sensitive and secure manner. It is expected that treating clinicians will assist patients if necessary. For example, a clinician may offer to look after the plan if the patient is unable to do this for him or herself or they may give it to a carer if this is appropriate until such time as the patient is more able to manage this. However, the plan must still be prepared and be discussed with the patient in the most appropriate manner.

Q13. If a patient objects to the wishes of any guardian, family member or primary carer being taken into account, does this mean these people should get no information about the treatment plan?

A. No. The decision about disclosing information to family members and carers is separate and is governed by section 120A of the Mental Health Act. Generally clinicians will seek the consent of the patient to disclose information to family and carers and this subject should be broached as soon as practicable in the treating relationship. However, if the patient does not give consent, section 120A(3)(ca) permits the giving of information to a guardian, family member or primary carer if the information is reasonably required for the ongoing care of the patient and the person receiving the information will be involved in providing that care. The decision to disclose information without the patient's consent is a clinical judgement that should take into account all the circumstances of the case and should have regard to the best interests of the patient.

Q14. Does a new treatment plan need to be prepared when the plan is reviewed or can the existing plan be amended/changed?

A. Generally a new plan should be prepared. The treatment plan is a clinical record and consistent with the requirements of the Health Records Act 2001 and the Public Records Act 1973, health information should not be deleted, amended or changed.
It is possible to add further information to the treatment plan, for example, an additional page could be attached to the plan with new information, while retaining any information that has not changed, such as the names of the treating team.

Q15. Does the authorised psychiatrist need to discuss the treatment plan with a patient subject to a Community Treatment Order (CTO) that is being supervised by a private psychiatrist (the "supervising medical practitioner")?

A. No. Section 19A(6) of the Act provides that a registered medical practitioner can give and discuss the plan with the patient.
However, the authorised psychiatrist provides consent for psychiatric treatment for involuntary patients and therefore is responsible for the patient's treatment and care and the treatment plan. The authorised psychiatrist for a patient subject to a CTO (the "monitoring psychiatrist") is responsible to monitor the progress of the patient and to review and revise the patient's treatment plan as required.

Q16. Do I need to send a copy of the MHA4 treatment plan to the Chief Psychiatrist?

A. No. Some forms have been circulated with instructions indicating that a copy should be sent to the Chief Psychiatrist. This is an error that will be corrected as soon as possible.
A copy of the MHA4 treatment plan should be provided to:

• patient
• patient's clinical record
• last (half-page) copy should go to administration for data entry purposes into the CMI

Q17. When members of the treating team change, does the treatment plan need to be varied?

A. Yes, but the timing for updating the treatment plan has been left to local discretion.
AMHS are expected to develop policies and procedures for the preparation, review and revision of treatment plans that are consistent with the legislative requirements.
The Treatment Plan (MHA 4) form is a two-page document. AMHS may choose to just update the front page whenever members of the treating team change.
Alternatively, the draft treatment plan guidelines recommend that, where reasonably practicable, the review of treatment plans should be aligned to existing clinical processes for efficiency purposes; for example, Mental Health Review Board hearings, Individual Service Plan (ISP) reviews and outcome measurement reviews. AMHS may choose to only update the details of the treating team when the plan itself is reviewed and revised.
However, patients do need to know who is responsible for their treatment. This is a key purpose of treatment plans. Where an AMHS decides that treatment plans will not be updated immediately when a member of the treating team changes, the details of the changes should still be communicated to the patient. In these circumstances, it might be in a less formal manner (for example, a business card or a letter), rather than revising the entire treatment plan.

FAQ - Community treatment orders (CTO)

Q1. Can a patient subject to a community treatment order receive treatment in an inpatient service without revoking the CTO?