of this Act or any of them, by summary application to the Court of Session, or to any sheriff court having jurisdiction over the respondent in such application, and it shall not be necessary to proceed by way of ordinary action.

112. Every inspector of the poor shall, within seven days after he shall have become aware of any pauper lunatic being within the parish of which he is inspactor, notify the same to the chairman of the parochial board, and he shall also within the same period intimate to the Board of Commissioners in lunacy under this Act the name and residence of such pauper lunatic, and all the circumstances he may have ascertained regarding his state and condition, together with the steps that may have been taken in reference to the care and custody of such pauper lunatic; and if any such inspector shall fail within the said period to make such notification and intimation, or either of them, he shall be liable in a penalty of 101.

113. Whereas by an Act passed, 8 & 9 Vict. c. 83, intituled 'An Act for the Amendment and better Administration of the Laws relating to the Relief of the Poor in Scotland,' the board of supervision thereby established is authorized and empowered, on any parochial board refusing or neglecting to provide for the removal of an insane or fatuous poor person to an asylum or establishment legally authorized to receive any lunatic patients, to take such measures as may be necessary for removing such insane or fatuous poor persons to such lunatic asylum or establishment; and it is thereby provided, that under special circumstances in particular cases the said board of supervision might dispense with such removal: The said Act, in so far as it grants such powers to the said Board of supervision shall be and the same is hereby repealed.

114. The assessing clauses of this Act shall not extend to the county of Shetland.

SCHEDULES to which the foregoing Act refers.

SCHEDULE (A.)

FORM of SUMMONS by the COMMISSIONERS.

IN the Matter of A.B., a Lunatic [or an insane Person, or an Idiot, or a Person of unsound Mind]. I, one of the Board of the Commissioners in Lunacy for Scotland, in pursuance of the Provisions of an Act passed in the Twenty-first Year of the Reign of Her Majesty Queen Victoria, intituled [insert the Title of this Act], do hereby grant Warrant to Messengers-at-Arms and Sheriff Officers conjunctly and severally to summon, warn, and charge and each of them, personally or at their respective Dwelling Places, in common Form, to appear before me at [insert Place], on the Day of o'Clock noon, and then and there to testify and bear witness, so far as they and each of them know and shall be asked, concerning the aforesaid Matter, under the Penalties specified in the said Act. Given at Edinburgh this in the Year One thousand eight hundred and

Day of

18 at

SCHEDULE (B.)

C.D., Commissioner.

FORM of LICENCE by the COMMISSIONERS.

I, one of the Board of the Commissioners in Lunacy for Scotland, do hereby certify, That E.F. of

the Parish of

of

and County of

in

in Number [or, in the

Patients],

has delivered to me a Flan and Description of a House and Premises proposed to be licensed for the Reception of Lunatics situated at in the County in which it is proposed to receive Patients not exceeding Case of a renewed Licence, has delivered to me a List of the Number of Patients now detained in a House and Premises situated at in the County of in which there are at present and the Board having considered and approved of the same do hereby authorize and empower the said E.F. [be intending or not intending to reside therein] to use and employ the said House and Premises for the Reception Male [or Female or are Paupers, for the Space of Given at Edinburgh this Day of

of

whereof

and

Male and
Female] Lunatics,
Calendar Months from this Date.
in the Year One thousand eight hundred
C.D.,
Commissioner.

SCHEDULE (C.)

FORM OF STATEMENT to be lodged with a PETITION to the SHERIFF for the RECEPTION of a LUNATIC.

1. Christian Name and Surname of Patient at Length.

2. Sex and Age.

3. Married, single, or widowed.

4. Condition of Life, and previous Occupation (if any).

5. Religious Persuasion so far as known.

6. Previous Place of Abode.

7. Place where found and examined.

8. Length of Time insane.

9. Whether first Attack.

10. Age (if known) on first Attack.

11. When and where previously under Examination, and Treatment.

12. Duration of existing Attack.

13. Supposed Cause.

14. Whether subject to Epilepsy. 15. Whether suicidal.

16. Whether dangerous to others.

17. Parish or Union to which the Lunatic [if a Pauper] is chargeable.

18. Christian Name and Surname and Place of Abode of nearest known Relative of the Patient, and Degree
of Relationship (if known), and whether any Member of his Family known to be or to have been insane.
19. Special Circumstances (if any) preventing the Insertion of any of the above Particulars.

I certify, That to the best of my Knowledge the above Particulars are correctly stated.
Dated this
One thousand eight hundred and

Day of

[To be signed by the Party applying.]

SCHEDULE (D.)

FORM OF MEDICAL CERTIFICATE.

I, the undersigned, [set forth the Qualification entitling the Person certifying to grant the Certificate, e.g., being a Member of the Royal College of Physicians in Edinburgh,] and being in actual Practice as a [Physician, Surgeon, or otherwise, as the Case may be], do hereby certify on Soul and Conscience, That I have this Day at [insert the Street and Number of the House (if any) or other like Particulars,] in the County of separately from any other Medical Practitioner visited and personally examined A. B. [insert Designation and Residence, and if a Pauper state so], and that the said A.B. is a Lunatic [or an insane Person, or an Idiot, or a Person of unsound Mind], and a proper Person to be detained under Care and Treatment, and that I have formed this Opinion upon the following Grounds, viz. :—

1. Facts indicating Insanity observed by myself [state the Facts].

2. Other Facts (if any) indicating Insanity communicated to me by others [state the Information, and from whom]. (Signed) [Name and Medical Designation and Place of Abode.] One thousand eight hundred and

Dated this

Day of

of

SCHEDULE (E.)

FORM of ORDER to be granted by the SHERIFF for the RECEPTION of a LUNATIC.

I, G. H., Sheriff [or Sheriff Substitute, or Steward, or Steward Substitute] of the County [or Stewartry having had produced to me, with a Petition at the instance of I. K. [Name and Designation], Certificates under the Hands of and being Two Medical Persons duly qualified in Terms of an Act [specify this Act], setting forth that they had separately visited and examined A.B. [describe him, and if a Pauper state so, and that the said A.B. is a Lunatic, [or an insane Person, or an Idiot, or a Person of unsound Mind], and a proper Person to be detained and taken care of, do hereby authorize you to receive the said A. B. as a Patient into the Public [or Private] Asylum of and I authorize his Transmission to the said Asylum accordingly, and I transmit to you herewith the said Medical Certificates, and a Statement regarding the said A. B. which accompanied the said Petition. Dated this

Day of

18

To the Superintendent of the Public Asylum [or Private Asylum] of

VOL. XXXV.-STAT.

2 E

SCHEDULE (F.)

NOTICE OF ADMISSION.

I HEREBY give Notice, That A. B. [describe him] was received into this House as a Private [or Pauper] Patient, on the Day of and I hereby transmit a Copy of the Order and Medical Certificates and Statement on which he was received. Subjoined is a Report with respect to the mental and bodily. Condition of the above-named Patient. (Signed) E. F., Superintendent. One thousand eight hundred and

Dated at

this

Day of

REPORT.

I have this Day seen and personally examined A. B., the Patient named in the above Notice, and hereby report and certify, with respect to his mental State, that [insert Particulars], and with respect to his bodily Health and Condition, that [insert Particulars]. (Signed) L.M., Physician [or Surgeon]. One thousand eight hundred and

Dated this

Day of

SCHEDULE (G.)

I, L. M., a Medical Person duly qualified in Terms of the Act [specify this Act], certify, on Soul and Conscience, That C. D. [name and design the Patient] is afflicted [state the Nature of the Disease], but that the Malady is not confirmed, and that I consider it expedient, with a view to his Recovery, that he should be placed [specify the House in which the Patient is to be kept] for a temporary Residence of [specify a Time, not exceeding Six Months].

WE

SCHEDULE (K.)
No. 1.

FORM of ASSIGNATION in SECURITY to be granted for MONIES BORROWED on the SECURITY of

ASSESSMENTS.

Assignation in Security No. [insert Number].

Members of the

District Board under the Act [specify this Act], in pursuance of the Powers of the said Act, do hereby, in consideration of the Sum of [specify Sum advanced], assign to [name and design Creditor], and his Heirs, Executors, and Assignees, [or as the Case may be], all the District Assessments to be raised and paid within the said District under the said Act, in Security of the Repayment of the said Sum of and of the Interest thereof after the Rate of Day of until Payment, which Sum is to be repayable, with the Interest at the Rate foresaid, as follows: [state the Terms of Repayment according to the Arrangement]. And we consent to Registration. In witness whereof [insert Testing Clause in common Form].

Pounds per Centum per Annum from the

No. 2.

FORM OF TRANSFER of ASSIGNATION in SECURITY.

I [Name and Designation], transfer to [Name and Designation], and his Heirs, Executors, and Assignees, an Assignation in Security, numbered [insert the Number of the Assignation], and dated [insert Date], granted by the District Board of the District to [Name and Designation], for [insert the Sum], and Day of And I consent to Registration.

the Interest thereof from the

In witness whereof [insert Testing Clause in common Form].