FORM I
(See Rule 15)
Application for maintaining a psychiatric hospital/nursing home

To
The……………….. Officer,
Government of …………………………..
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) Inpatient 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 Rs ……….. drawn in favour or ………… as licence fee.
I hereby undertake to abide by the rules and regulation 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,
Signature ……….
Name …………..
Date …………..