The circumstances under which this Petition is presented by
me are as follows:—
5. I am not related to or connected with either of the persons
signing the certificates which accompany this petition as (where
the petitioner is a man) husband, father, father-in-law, son,
son-in-law, brother, brother-in-law, partner, or assistant (or
where the petitioner is a woman) wife, mother, mother-in-law,
daughter, daughter-in-law, sister, sister-in-law, partner, or assistant.
6. I undertake to visit the said_____________________________
__________________________personally, or by some one specially
appointed by me, at least once in every six months while under
care and treatment under the order to be made on this petition.
7. A statement of particulars relating to the said________________
______________________________________accompanies this petition.
If it is the fact, add: 8. The said_____________________
has been received in the Haydock Lodge Licensed House,
Newton-le-Willows, under an Urgency Order dated the____________
________________________________________________________
The petitioner therefore prays that an order may be made in
accordance with the foregoing statement.
Signed (k)_______________________________________
Date of Presentation of the Petition, this____________
day of___________________ 19_________