SCHEDULE (C), No. 1.

Names of all Pauper Lunatics in the Asylum at

for the County [or Borough, etc., as the case may be], of on the

day of

18

Names of all Private Lunatics in the Asylum at

for the County [or Borough, etc., as the case may be], of

Name.

SCHEDULE (D).

Form of Annual Return.

A true list of all lunatics, idiots, and other persons of unsound mind, chargeable to the common fund, or to the parishes comprised within [such part of] the union [as is situate] [or to the parish of ] in the county of specifying the names, sex, and age of each, and whether dangerous or otherwise, and for what length of time they have been supposed to be of unsound mind, and where detained, or how otherwise disposed of.

Clerk to the board of guardians of the said union

[or overseers of the said parish].

I declare that I have personally examined the several per

sons whose names are specified in this list, on the days set opposite to their names, and that they are all [or all except A. B., C. D., and E. F.] properly taken care of, and may properly remain out of an asylum, and that these are the only pauper lunatics, to the best of my knowledge, in the district of the union [or in the parish] of

who are not in

an asylum, registered hospital, or duly licensed house.

(Signed) A. B.

Medical officer of the
of the union [or parish] of

district

Dated the

day of

18

SCHEDULE (F), No. 1.

Order for the Reception of a Pauper Patient.

I, C. D., [in the case of a single justice of the peace, or in the case of two justices, or of a clergyman and relieving officer, etc., We, C. D., and E. F.], the undersigned, having called to my [or our] assistance a physician [or surgeon, or apothecary, as the case may be], and having personally examined A. B., a pauper [omit the words "a pauper" when the lunatic is not a pauper], and being satisfied that the said A. B. is a lunatic [or an idiot, or a person of unsound mind], [add, where the lunatic is sent as being wandering at large, the words "wandering at large," and in the case of a lunatic sent by virtue of the authority given to two justices, add "not under proper care and control," or "and is cruelly treated [or neglected] by the person having the care or charge of him," as may appear to the justices to be the case], and a proper person to be taken charge of and detained under care and treatment, hereby direct you to receive the said A. B. as a patient into your asylum [or hospital, or house]. Subjoined is a statement respecting the said A.B.

Dated the

Το

county of

house of

or house].

of

* A justice of the peace for the city [or borough] [ or an or the officiating clergyman of the parish of

(Signed) E.F.

]

superintendent of the asylum for the

or the lunatic hospital of

or proprietor of the licensed [describing the asylum, hospital,

NOTE. Where the order directs the lunatic to be received into any asylum other than an asylum of the county or borough in which the parish or place from which the lunatic is sent is situate, or into a registered hospital or

* To be signed by two justices, where required by the foregoing Act.

licensed house, it should state that the justice or justices or other persons making the order is or are satisfied that there is no asylum of such county or borough, or that the asylum or asylums thereof is or are full; or (as the case may require) the special circumstances by reason whereof the lunatic cannot conveniently be taken to an asylum for such first-mentioned county or borough.

STATEMENT.

[If any Particulars in this Statement be not known, the Fact to be so stated].

Name of patient, and christian name, at length.

Sex and age.

Married, single, or widowed.

Condition of life, and previous occupation (if any).

The religious persuasion, as far as known.

Previous place of abode.

Whether first attack.

Age (if known) on first attack.

When and where previously under care and treatment.

Duration of existing attack.

Supposed cause.

Whether subject to epilepsy.

Whether suicidal.

Whether dangerous to others.

Parish or union to which the lunatic is chargeable (if a pauper or destitute lunatic).

Name and christian name and place of abode of the nearest known relative of the patient, and degree of relationship (if known).

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

(Signed)

[In the case of a pauper to be signed by

the relieving officer or overseer.]