Appendix A: Mental Health Act Forms

AuthorRichard D. Schneider
Pages522-578
522 ANNOTATED ONTARIO MENTAL HEALTH STATUTES
1118–41 (94/03) 7530–5255
Application for Volunteer Service
Demande – Offre de services de bénévole
Name/Nom
All volunteers are requested to attend periodic training and resource sessions relevant to their service
assignment with a psychiatric population.
Tous les bénévoles doivent suivre des séances de formation et d’information périodiques en rapport avec les
services qu’ils dispensent aux patients de l’établissement psychiatrique.
Address /Adresse
Occupation
Profession
Hobbies, interest
(e.g. crafts, music, sports, etc.) (optional)/
Passe-temps, intérêts
(p.. ex. artisanat, musique, sports, etc.) (facultatif)
Community affiliation/Affiliation communautaire
Mr./M.
Ministry
of
Health
Ministère
de
la Santé
Miss/Mlle
Mrs./Mme
Ms./Mme
Age range/Catégorie d’âge
under 18
(please complete Parental Consent Form 2050–41)
moins de 18 ans
(faites remplir la formule 2050–41
Consentement parental)
18 – 59 59+
Date of birth
(optional)/
Date de naissance
(facultatif)
Postal code/Code postal Telephone no./No de téléphone
Place of employment/Lieu de travail Can you be contacted at work?
Peut-on vous joindre au travail? Telephone no./No de téléphone
yes/oui no/non
student
étudiant/e
Languages spoken/Langues parlées Languages read/Langues lues
Why do you want to volunteer at this facility?/Pourquoi voulez-vous être bénévole dans cet établissement?
Have you had any academic/volunteer/practical experience related to work in a psychiatric facility?
Avez-vous une expérience académique/pratique/de bénévole en rapport avec le travail dans un établissement psychiatrique?
Name of facility/Nom de l’établissement
Academic background
(optional)/Niveau d’études (facultatif)
high school
études secondaires
college
(specify program)
collège
(précisez le programme)
university
(specify program)
université
(précisez le programme)
trade or technical (specify program)
école de métier ou école technique
(précisez le programme)
other
(specify)
autre
(précisez)
Clear/Replacer
1118–41 (94/03) 7530–5255
Address /Adresse
City/Ville Postal code/Code postal
Telephone no.
(Res.)/
Node tél.
(rés.)
Oath of confidentiality/Serment de confidentialité
Date Witness/Témoin
Please recommend two people who would support your interest in participating as a volunteer in this facility.
(One who is known to this facility and a professional in the community who will be required to complete a written reference.)
Veuillez nous donner le nom de deux personnes qui appuient votre désir de travailler comme bénévole dans cet établissement.
(L’une de ces personnes doit nous être connue et l’autre être un(e) professionnel(elle) oeuvrant dans la communauté à qui on demandera de fournir une lettre de
référence.)
Orientation
Name/Nom
Telephone no.
(Bus.)//
Node tél.
(trav.)
Address //Adresse
City/Ville Postal code//Code postal
Telephone no.
(Res.)//
Node tél.
(rés.)
Name/Nom
Telephone no.
(Bus.)///
Node tél.
(trav.)
Please include any further information that might be useful:/Veuillez inclure tout autre renseignement pouvant nous être utile :
Name of person to contact in case of emergency
Nom de la personne à contacter en cas d’urgence Relationship/Lien
Address/Adresse
Place of employment
(if applicable)/
Lieu de travail
(s’il y a lieu)
Telephone no.
(Res.)/
Node tél.
(rés.)
Telephone no.
(Bus.)//
Node tél.
(trav.)
I, _________________________________________, as a
Volunteer/Placement Student at the
______________________________________, do pledge that I
will perform to the best of my ability any task that is given me, to be
punctual and conscientious in the fulfilment of my duties and to
consider as confidential all information which I may hear or learn of
through my duties concerning patients/clients and their families,
staff, Placement Students and Volunteers
Signature
For Office Use Only/Réservé au bureau
Group/Groupe Individual/Personne Date of interview/Date de l’entrevue
Reference sent/Réf. envoyée Reference received/Réf. reçue Service agreement completion date/
Date de fin de l’entente de service
Assignment/Affectation Location/Emplacement Day/Time/Jour/Heure
This information is collected pursuant to section 7 of the
, R.S.O. 1990, c.M.8. The principal purpose for the collection is to assist with the recruitment and evaluation of volunteers in provincial
psychiatric hospitals. For more information, please contact the Director of Volunteer Services at the provincial psychiatric hospital where you obtained this application.
Les présents renseignements sont réunis conformément à l’article 7 de la
Loi sur les hôpitaux psychiatriques,
L.R.O. 1990, chap. M.8. Cette collecte a pour principal objectif de faciliter le recrutement et l’évaluation
des bénévoles dans les hôpitaux psychiatriques de la province. Pour obtenir de plus amples renseignements, communiquez avec le directeur ou la directrice des services de bénévoles de l’hôpital psychiatrique
provincial où vous avez obtenu la présente demande.
Indicate your time availability
(include a second and third choice where possible)
Combien de temps êtes-vous disponible?
(indiquez un deuxième et un troisième choix, si possible)
It is preferred that volunteers make a six month commitment to the volunteer program at/On préfère que les bénévoles s’engagent pour une période de six mois à
Willing to volunteer for/Je suis prêt(e) à offrir mes services pour
6 months
6 mois longer than 6 months
plus de six mois
Are you willing to volunteer for on-call events as they arise?
Acceptez-vous d’être en disponibilité pour certaines activités de dernière minute?
yes/oui no/non
How did you learn about volunteer services at our facility?/Comment avez-vous appris l’existence des services de bénévoles dans notre établissement?
Please note: Volunteer programs operate seven days a week – day-time and early evenings.
Nota : Les programmes de bénévoles fonctionnent sept jours sur sept – pendant la journée et en début de soirée.
1. Day/Jour
Time/Heures
am/pm
2. Day/Jour
Time/Heures
am/pm
3. Day/Jour
Time/Heures
am/pm
other
(specify)
autre
(précisez)
Je soussigné(e) _________________________________________, en ma qualité de
bénévole/d’étudiant(e) en placement à
______________________________________, m’engage à m’acquitter, au mieux de
mes capacités, de toute tâche qui m’est confiée, d’être ponctuel(elle) et
consciencieux(euse) dans mon travail et de considérer comme confidentielle toute
information que je peux surprendre ou apprendre dans le cours de mes activités sur
les patients/clients et leur famille, le personnel, les étudiants en placement et les
bénévoles.
Appendix A: Mental Health Ac t Forms, Application for Volunteer Service 523
© Queen’s Printer for Ontario, 2003. Reproduced wit h permission.
524 ANNOTATED ONTARIO MENTAL HEALTH STATUTES
Community Treatment Order
(CTO) Information Record
1. Patient’s date of birth
Ministry of Health
and Long-Term Care
Confidential when completed
Patient’s first and last initials 2. Date of issue
Organization/agency name and address
3. Patient’s and physician’s service affiliation at time CTO is issued:
(check one only)
Hospital Inpatient Psychiatry
Print name of person completing this form Date
Issuing physician name
Private Practice
Other
(specify)
yyyy mm dd yyyy mm dd
Hospital Outpatient Psychiatry/Mental Health
Community Mental Health Program
(specify)
Assertive Community Treatment (ACT)
4. Consent provided by: client / patient substitute decision-maker
5. Community Treatment Order 1st issue renewal re-issue
If more than one
, specify the total number of CTOs patient has had
(include the current one):
Mail completed form to:
Administrative Assistant, CTO Information Project
Finance and Information Management Branch
5700 Yonge Street, 4th Floor
Toronto ON M2M 4K5
6. Sex male female 7. No. of psychiatric hospitalizations in past
6 months
:admissions
8. Patient service involvement during previous 6 months
(check all that apply)
Hospital Inpatient Psychiatry
Crisis Intervention
Private Psychiatrist
Hospital Outpatient Psychiatry/Mental Health
Assertive Community Treatment (ACT)
Supportive Housing
Medication Management / Clinic
Addiction Service
Non-psychiatric Medical Care
None Don’t know
Community Mental Health Program(s)
(specify)
Other service(s)
(specify)
9. Services to be involved in the current CTO
(check all that apply)
Hospital Outpatient Psychiatry/Mental Health
Assertive Community Treatment (ACT)
Addiction Service
Crisis Intervention
Case Management
Private Psychiatrist
Medication Management / Clinic
Supportive Housing
Non-psychiatric Medical Care
Community Mental Health Program(s)
(specify)
Other service(s)
(specify)
10. Patient involvement with legal system during previous 6 months
(check all that apply)
Apprehended under the Mental Health Act
Probation and/or Parole
None
Criminal Arrest
Victim of Crime
Don’t know
Incarcerated
Court Diversion
Other legal involvement
(specify)
11. Psychiatric diagnoses:
(check all that apply)
Schizophrenia
Other Psychotic Disorder
Personality Disorder
Schizoaffective Disorder
Substance/Alcohol Related Disorder
Developmental Disorder
Bipolar Disorder
Depression
Other disorder(s)
(specify)
12. (a) Lives with:
(check all that apply)
Spouse/Partner Parent(s) Child(ren) Other family
Non-family person(s) Self Don’t know
(b) Housing type:
(check only one)
Private house/condo Market Rental Unit
(apartment, flat or house) Subsidized rental unit Room and board
Homes for Special Care Approved Home Retirement/Seniors Home Hostel/Shelter
Correctional/Probation facility Other institutional facility with no
fixed address Homeless/On street Don’t know
Other housing
(specify)
Telephone no.
()
Please read Instructions on reverse.
ER
NOTICE OF DATA COLLECTION BY THE MINISTRY OF HEALTH AND LONG–TERM CARE
The amended Mental Health Act (Bill 68) requires that the Minister of Health and Long-Term Care establish a process to review
community treatment orders (CTOs). The Ministry of Health and Long-Term Care has been given authority by the Information and
Privacy Commissioner/Ontario to collect patient information indirectly from physicians who issue, renew or re-issue CTOs. The
information collected will be anonymous and will be used for the sole purpose of establishing and conducting reviews of
community treatment orders as set out in section 33.9 of Bill 68.
If you have any questions or concerns about the collection of this information, or require further information, please contact
Manager, Monitoring, Standards and Evaluation, Operational Support Branch, Ministry of Health and Long–Term Care, 5700
Yonge St., Mezzanine Level, Toronto ON M2M 4K5, Telephone: (416) 327–7350.
Please detach this Notice and give to the patient or Substitute Decision-Maker who provided consent on the CTO.
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