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FORM I

(See rule 15)
Application for maintaining a Psychiatric hospital/Nursing home under
sub-section (1) of section 7 of the Act.
To      
  The Licensing Authority    
  ……………………………………………………    
  ……………………………………………………    
Dear Sir/Madam,    
I/We intend to establish/maintain a psychiatric hospital/psychiatric nursing home in respect of which I am/we are holding a valid licence for the establishment/maintenance of such hospital/nursing home. The details of the hospital/nursing home are given below:
1. Name of Applicant :  
2. Details of licence with reference to
the name of the Authority issuing
the licence and date
:  
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 proposed nursing
home/hospital
   
8. Proposed accommodations    
  (a) Number of rooms :  
  (b) Number of beds :  
Facilities provided :    
  (a) Out-patient    
  (b) Emergency services    
  (c) In-patient facilities    
  (d) Occupational and recreational
facilities
   
  (e) ECT facilities    
  (f) X-ray facilities    
  (g) Psychological testing facilities    
  (h) Investigation and Laboratory facilities    
  (i) Treatment facilities    
Staff pattern:    
  (a) Number of Doctors :  
  (b) Number of Nurses :  
  (c) Number of Attenders :  
  (d) Others :  
  I am sending herewith a bank draft for ₹……………drawn in favour of………………….as licence fee.
  I hereby undertake to abide by the rules and regulations of the Mental Health Authority.
  I request you to consider my application and grant the licence for establishment/maintenance of psychiatric hospital/nursing home.
    Yours faithfully,  
Place :   Signature :  
Date :   Name :  
       

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