Appendix A: Mental Health Act Forms

• Author: Richard D. Schneider
• Pages: 522-578

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

Mental Hospitals Act

, 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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