3. General restlessness of manner; considers himself heavily involved in debt to many thousands of pounds, _whereas his debts do not amount to a few hundreds_; says he has been ruined by the Government, _whereas he has only been dismissed from his appointment on account of his incapacity_; and he intends prosecuting the Admiralty for £5000 damages, _he having no real ground of action_. (This was twice sent back for correction, the first correction being--_By these statements I was satisfied that the patient was of unsound mind, and by his general conduct during examination._ Finally amended as given above.) [Sidenote: (_a_)--a Justice of the Peace for ____, _or_ His Honour the Judge of the County Court of ____, _or_ ____ Stipendiary Magistrate for ____. (_b_) Full postal address and rank, profession, or occupation. (_c_) At least twenty-one. (_g_) Some day within 14 days before the date of the presentation of the petition. (_h_) Here state the connection or relationship with the patient. (_k_) Full Christian and surname.] 53 Vict. c. 5.--Sched. 2, Form 1. PETITION FOR AN ORDER FOR RECEPTION OF A PRIVATE PATIENT In the Matter of_______________________________ a person alleged to be of unsound mind. _To_ (_a_)____________________________________ ____________________________________ ____________________________________ The Petition of_________________________________________ of (_b_)_________________________________________ _________________________________________ in the County of________________________________________ 1. I am___________(_c_) years of age. 2. I desire to obtain an Order for the Reception of ________________________________________________ as a person of unsound mind, in the Haydock Lodge Licensed House, situate at Newton-le-Willows, Lancashire. 3. I last saw the said__________________________________ at______________________________________________________ on the (_g_)_______day of________________ 19_______ 4. I am (_h_)_______________________________ of the said____________________________________________________ (or if the Petitioner is _not connected_ with or related to the or Patient, _state as follows_:) I am not related to or connected with the said__________ ________________________________________________________ The reasons why this Petition is not presented by a relation or connection are as follows: The circumstances under which this Petition is presented by me are as follows:--