Mental Health and Wellbeing Act 2022 forms

The department has developed the following forms to support the implementation of the Mental Health and Wellbeing Act 2022 (the Act). .

Services can download and print forms from the website or order hard copies of selected forms from Allanby Press Printers.

The MHWA125 notice of death form is available on the Chief Psychiatrist’s website.

Assessment Order forms

MHWA 101 Assessment Order 

PDF 1.83 MB

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MHWA 102 Receipt of person subject to Inpatient Assessment Order

PDF 830.19 KB

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MHWA 103 Variation of Assessment Order 

PDF 1.63 MB

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MHWA 104 Extension of Assessment Order 

PDF 1.75 MB

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MHWA 105 Revocation of Assessment Order 

PDF 1.21 MB

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MHWA 106 Variation of Court Assessment Order 

PDF 1.28 MB

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Temporary Treatment Order and Treatment Order forms

MHWA 110 Temporary Treatment Order

PDF 1.94 MB

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MHWA 111 Variation of Temporary Treatment Order or Treatment Order 

PDF 2 MB

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MHWA 112 Revocation of Temporary Treatment Order or Treatment Order 

PDF 1.85 MB

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MHWA 113 Application for another Treatment Order 

PDF 1.77 MB

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MHWA 114 Application to Mental Health Tribunal  

PDF 1.55 MB

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Operational forms (leave, transfer etc)

MHWA 120 Leave of absence for compulsory patient 

PDF 1.71 MB

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MHWA 122 Revocation of leave of absence for compulsory patient 

PDF 1.41 MB

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MHWA 123 Transfer of a compulsory patient to another designated mental health service

PDF 341.64 KB

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MHWA 124 Taking care and control of patient absent without leave 

PDF 173.34 KB

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MHWA 126 Taking care and control of a patient on a varied order

PDF 132.26 KB

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Treatment, applications and consent

MHWA 130 Substitute consent to medical treatment by authorised psychiatrist 

PDF 1.88 MB

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MHWA 131 Informed consent to ECT 

PDF 1.77 MB

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MHWA 131A Informed consent to ECT by medical treatment decision maker

PDF 2.41 MB

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MHWA 132 Application for electroconvulsive treatment (ECT)

PDF 1.96 MB

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MHWA 132A Application for ECT - Voluntary Adult without capacity to consent 

PDF 1.33 MB

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Restrictive interventions

MHWA 144 Right to restrict communication

PDF 198.15 KB

Updated 27 Aug 2025

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MHWA 145 Authority for use of restrictive interventions including chemical restraint and observation

PDF 203.74 KB

Updated 27 Aug 2025

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MHWA 145A Restrictive interventions observation continuation

PDF 174.13 KB

Updated 27 Aug 2025

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MHWA 146 Authority for urgent physical restraint and observations

PDF 204.78 KB

Updated 27 Aug 2025

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Note the new MHWA 145 form replaces the MHWA 140, MHWA 141, MHWA 142 and MHWA 143 forms. These forms will be phased out by December 2025.

MHWA 140 Authority for use of restrictive interventions  

PDF 2.7 MB

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MHWA 141 Authority for urgent physical restraint 

PDF 2.45 MB

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MHWA 142 Restrictive interventions observations

PDF 1.13 MB

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MHWA 143 Authority for use of chemical restraint  

PDF 2.98 MB

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Guidelines regarding the use of chemical restraint are published by the Office of the Chief Psychiatrist.

Security and forensic patients

MHWA 150 Receipt of security or forensic patient 

PDF 888.56 KB

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MHWA 151 Leave of absence for security patient 

PDF 1.71 MB

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MHWA 153 Revocation of leave of absence for security patient 

PDF 1.63 MB

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MHWA 154 Special leave of absence for forensic patient 

PDF 838.61 KB

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MHWA 155 Application for monitored leave for security patient 

PDF 1.33 MB

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MHWA 156 Transfer of security or forensic patient 

PDF 1.61 MB

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MHWA 157 Discharge of security patient 

PDF 1.71 MB

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MHWA 158 Report of psychiatrist 

PDF 1.59 MB

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MHWA 159 Report of authorised psychiatrist 

PDF 1.55 MB

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Cross border

MHWA 170 Interstate transfer of compulsory patient with consent 

PDF 832.31 KB

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MHWA 171 Interstate transfer of compulsory patient without consent

PDF 898.97 KB

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Admissions, registration and separations

MHWA PR 1 Registration - Demographics

PDF 1.02 MB

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MHWA PR 1a Registration - Legal and clinical

PDF 866.05 KB

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MHWA PR 2 Admission

PDF 961.71 KB

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MHWA PR 5 Separation

PDF 891.24 KB

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Advance statement of preferences

Forms for making or revoking an advance statement of preferences are on the advance statement of preferences page.

Nominated support persons

Forms for nominating a nominated support person or revoking a nomination can be found on the nominated support persons page.

Access to archived mental health information

Access to archived mental health information held by the Department of Health can be requested through Freedom of Information or via email at foi@health.vic.gov.au