Certificate of Emergency Treatment
Section 64G of the Mental Health Act 1983 (as amended)
FOR TREATMENT UNDER PART 4A (CTO Patient) – MEDICATION (NOT ECT)
Patient Name
I am the registered medical practitioner who is in charge of the treatment of the above named
patient.
In my opinion, I believe that the patient lacks capacity to consent to the treatment plan.
The treatment plan is:
I consider that it is necessary to give urgent treatment to this patient without consent or
authorization by a Second Opinion Appointed Doctor (tick one as appropriate):
 which is immediately necessary to save the patient’s life; or
 which (not being irreversible) is immediately necessary to prevent a serious deterioration of the
patient’s condition; or
 which (not being irreversible or hazardous) is immediately necessary to alleviate serious
suffering by the patient; or
 which (not being irreversible or hazardous) is immediately necessary and represents the
minimum interference necessary to prevent the patient from behaving violently or being a
danger to himself or to others.
This certificate will allow me to (tick one as appropriate):
 allow me to initiate the treatment plan; OR,
 allow me to continue the current treatment plan.
Urgent treatment under this section can only continue for as long as it remains immediately
necessary. If it is no longer immediately necessary, the normal requirements for
certificates apply (CoP 24.35).
Signed:
………………………………………………….
Printed:
………………………………………………….
Date: …………………………
SOAD Requested on …………………………… [date] at ……………… [time]
by …………………………………… [name].
Copy to be filed in patient’s copy legal file, and the original sent to MHA Administration
S 64G Certificate (Part 4A) (not ECT) - Website Version 1.1 – June 2011