Appendix B: Health Care Consent Act, 1996 Forms

• Author: Richard D. Schneider
• Pages: 580-595

580 ANNOTATED ONTARIO MENTAL HEALTH STATUTES

2973–04 (00/12)* 7530–5333www.ccboard.on.ca

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Application to the Board to Review a

Finding of Incapacity under Subsection

32(1), 50(1) or 65(1) of the Act

Form A

Health Care Consent Act

Are you currently an in-patient or resident at a health or residential facility?

yes name, address and telephone number of facility

no

(print full name )

My name is:

If this application refers to admission to a care facility, please provide the name, address, telephone and fax

numbers of the person responsible for authorizing admissions to the facility:

(Disponible en version française) See reverse

, I apply to the Board for a review of:

an evaluator’s finding that I am incapable with respect to my admission to a care facility.

an evaluator’s finding that I am incapable with respect to a personal assistance service.

a health practitioner’s finding that I am incapable with respect to the following treatment, course of

treatment, plan of treatment or community treatment plan:

Note: An application may only be made if a Health Practitioner or evaluator has made a relevant

finding of incapacity.

Please provide the name, address, telephone and fax numbers of the health practitioner or evaluator who

made the finding of incapacity:

Your home address and telephone number or other way to contact you:

(address) (telephone no.)

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Name, address, telephone number and fax number of your lawyer or agent

(if any):

(name) (address)

(name) (address)

Consent

and Capacity

Board

2973–04 (00/12)* 7530–5333www.ccboard.on.ca

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If this application refers to a personal assistance service, please provide the name, address, telephone and fax

numbers of the staff member responsible for the service:

Send this form by fax to the Office of the Regional Vice-Chair of the Board or call toll free at 1 800 461–2036 for assistance.

Collection of this information is for the purpose of conducting a proceeding before this Board. It is collected/used for this purpose under the authority of

subsection 32(1) / 50(1) / 65(1) of the Health Care Consent Act. For information about collection practices, contact the office of the Regional Vice-Chair of the

Board or call toll free at 1 800 461–2036.

(name) (address)

If someone helped you to fill out this application form, please provide his / her name, address, telephone and fax

numbers:

(name) (address)

Have you applied to the Board during the past year for a review of a finding regarding your capacity to consent to

treatment, admission to a long term care facility or personal care services?

yes if know, provide place and date of last hearing

no

(date) (location)

(date) (signature)

For your information

What will happen if I don’t apply to the Board? If you have been found incapable of consenting to a treatment, admission

to a long term care facility or a personal assistance service, someone else will be asked to make the decision for you. This is

usually a close family member. If you have a court-appointed guardian or an attorney for personal care with the authority to

make the decision, that person will make it for you.

Who may apply to the Board? Anyone who has been found incapable of consenting to a treatment, admission to a long

term care facility or a personal assistance service may apply unless:

Dthey have either a court-appointed guardian for personal care with authority to make the required decision, or

Dthey have signed a special kind of power of attorney for personal care in which they waive their right to apply to the

Board and which meets specific procedural requirements found in Section 50(1) the Substitute Decision Act.

Dmay not reapply within six months of a final determination of a previous application except with Board permission.

When & Where will the hearing be? The hearing will be held somewhere close to where you are. It will probably take

place within a week after the Board receives your application.

How will the Board make its decision? The Board will base its decision on whether or not it believes that you are:

Dable to understand the information that is relevant to making a decision concerning the treatment, admission to a long

term care facility or personal assistance service, and

Dable to appreciate the reasonable foreseeable consequences of a decision or lack of decision.

Form A

(page 2)

Appendix B: Health Care Consent Ac t, 1996 Forms, Form A 581

© Queen’s Printer for Ontario, 200 0. Reproduced with permission.