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Application by an Approved Mental Health Form A2

Professional for Admission for Assessment Mental Health Act 1983
Section 2 Regulation
4(lXa)(ii)

(name and address of
hospital)

(PRINT your full name

(PRINT your address) of

(PRINT full name of patient)
(PRINT address of
patient)

(PRINT name of local social
services authority)

delete as appropriate

(PRINT Full name
and address)

(PRINT fun name
and address)

Cal No. MHRZ LFX 31157

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