FORM VIII
(See Rule 25)
Application for reception order
(By relative or other)

To
..............................................................
Sir,
Subject: Admission of ………. son/daughter of ………….into psychiatry hospital nursing/home as inpatient.
            I ………….. son/daughter of …………. residing at ………… request you to kindly arrange ]or admission in respect of Sh./Smt ………… aged ……… Years .... son/daughter of ……… an inpatient to ………….. (name of the hospital) or any other hospital/nursing home. He/She has the following suggestive of mental illness,
1.
2.
3.
4.
5.
            I, who is........................... (relationship) of Sh./Smt.......................................... have an income Rs........................... and agree to pay the charges of treatment if any, according to the rules and also assure that I shall abide by the rules and regulations of the Institution. I state that I have/have not made such any previous application with regard to the mental condition of........................... as required. I herewith enclose, the two medical certificates needed for the purposes. '
Yours faithfully,
Witnesses :                                                                     Signature.......................................
                                                                                        Name in capital...........................
1. Name:
    Address:
2. Occupation: