Application form h.
Investigation and laboratory facilities
Form - I i. Treatment Facility
(See rule 15 of State Mental Health Rules, 1990) Staff Pattern:
Application for maintaining a Psychiatric Hospital / Nursing Home a. Number of doctors:
b. Number of Nurses:
To c. Number of Attenders:
The Licensing Authority, d. Others:
Govt. Institute of Mental Health, I am sending herewith a bank draft for Rs--------------- drawn in
Medavakkam Tank Road, favour of Director, Institute of Mental Health, Kilpauk, Chennai as
Kilpauk, Chennai - 600 010. licensing fee.
I hereby undertake to abide by the rules and regulation of the Mental
Dear Sir, Health Authority.
I/We intend to establish / maintain a Psychiatric Hospital / I request you to consider my application and grant the license for
Psychiatric Nursing Home in respect of which I am/we are holding a establishment / maintenance of Psychiatric Hospital / Nursing
valid license for the establishment / maintaining of such hospital / Home.
nursing home. The details of the hospital / nursing home are given
below:
1. Name of Applicant: Yours faithfully,
2. Details of license with reference to the name of the Authority
issuing the license and date:
3. Age: Signature:
4. Professional experience in Psychiatry: Date:
5. Permanent address of the applicant: Name:
6. Location of the proposed Hospital / Nursing Home:
7. Address of the proposed Hospital / Nursing Home:
8. Proposed accommodation:
a. Number of rooms
b. Number beds
Facilities provided:
a. Out-patient facility
b. Emergency services
c. Inpatients facilities
d. Occupational and recreational facilities
e. ECT facilities
f. X-ray facilities
g. Psychological testing facilities
Form – II Staff Pattern:
(See rule 15, State Mental Health Rules) a. Number of Doctors
Application for establishment of a Psychiatric Hospital / Nursing b. Number of Nurses
Home under sub-section (2) of Section 7 of Mental Health Act, 1987 c. Number of Attenders
d. Others
To I am sending herewith a bank demand draft for Rs. ___________
The Licensing Authority, drawn in favour of Director, Institute of Mental Health, Kilpauk,
Govt. Institute of Mental Health, Chennai as licensing fee.
Kilpauk, Chennai - 600 010. I hereby undertake to abide by the rules and regulation of the Mental
Health Authority. I request you to consider my application and grant
Dear Sir, the license.
I/We intend to establish / maintain a Psychiatric Hospital / Yours faithfully,
Psychiatric Nursing Home at (mention the place) I am
herewith giving you the details. Signature:
1. Name of Applicant: Date:
2. Qualification of Medical Officer to be in charge of Nursing Name:
Home/ Hospital (Certificate to be attached):
3. Age:
4. Professional experience in Psychiatry:
5. Permanent address of the applicant:
6. Location of the proposed Hospital / Nursing Home:
7. Address of the proposal Hospital / Nursing Home:
8. Proposed accommodation:
a. Number of rooms
b. Number beds
Facilities provided:
a. Out-patient facility
b. Emergency services
c. Inpatients facilities
d. Occupational and recreational facilities
e. ECT facilities
f. X-ray facilities
g. Psychological testing facilities
h. Investigation and laboratory facilities
i. Treatment Facility
