Appendix A: Mental Health Act Forms

• Author: Richard D. Schneider; Caitlin Pakosh; Lora Patton
• Pages: 549-609

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APPENDIX A

Mental Health Act Forms

Form  Application by Physician for Psychiatric Assessment

Form  Order for Examination under Section 

Form  Certicate of Involuntary Admission

Form  Certicate of Renewal

Form A Certicate of Continuation

Form  Change to Informal or Voluntary Status

Form  Order for Attendance for Examination

Form  Conrmation by Attending Physician of Continued Involuntary Status under Subsection

() of the Act

Form  Order for Admission

Form  Order for Return

Form  Memorandum of Transfer

Form  Transfer to a Public Hospital

Form  Order to Admit a Person Coming Into Ontario

Form  Statement by Attending Physician under Subsection () of the Act

Form  Application to the Board to Review a Patient’s Involuntary Status under Subsection ()

of the Act

Form  Notice to the Board of the Need to Schedule a Mandatory Review of a Patient’s Involun-

tary Status under Subsection () of the Act

Form  Application to the Board to Review a Finding of Incapacity to Manage Property under

section  of the Act

Form  Certicate of Incapacity to Manage One’s Property under Subsection () of the Act

Form  Financial Statement

Form  Notice of Cancellation of Certicate of Incapacity to Manage One’s Property Under

Section  of the Act

Form  Notice of Continuance of Certicate of Incapacity to Manage One’s Property Under

Subsection () of the Act

Form  Application to the Board to Review the Status of an Informal Patient who is a Child

between  and  Years of Age under Subsection () of the Act

Form  Notice to the Board of the Need to Schedule a Mandatory Review of the Status of an

Informal Patient who is a Child between  and  Years of Age under Subsection ()

of the Act

Form  Notice by Ocer-in-Charge to a Child who is between  and  Years of Age, who is an

Informal Patient under Subsection () of the Act

Form  Notice to Patient under Subsection () of the Act

Form  Notice to Patient under Subsection () of the Act and under Clauses ()(a) and

.(a) of Regulation 

Mental Health Act Forms

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Form  Notice to Person under Subsection . of the Act of Application for Psychiatric Assess-

ment under Section  or an Order under Section  of the Act

Form  Community Treatment Order

Form  Notice to Person of Issuance or Renewal of Community Treatment Order (Section

.())

Form  Order for Examination Sections .() and .() of the Act

Form  Application to Board to Review Community Treatment Order and Notice to Board by

Physician of Need to Schedule Mandatory Review of Community Treatment Order

Form  Notice of Intention to Issue or Renew Community Treatment Order (section .(),

section .())

Form  Conrmation of Rights Advice

Form  Application to the Board for Section . Orders under Subsection () of the Act

Form  Application to the Board for an Involuntary Patient’s Transfer to Another Psychiatric

Facility under Section () of the Act

Form  Application to the Board to Vary or Cancel Section . Orders of the Board under Sec-

tion () of the Act

Form  Application to the Board to Vary or Cancel Section . Orders of the Board under Sec-

tion () of the Act

Mental Health Act Forms Form 

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Ministry

of

Health

Form 

Mental Health Act

Application by Physician for

Psychiatric Assessment

Name of physician

(print name of physician)

Physician address

(address of physician)

Telephone number ( ) Fax number ( )

On I personally examined

(date) (print full name of person)

whose address is

(home address)

You may only sign this Form  if you have personally examined the person within the past seven days.

In deciding if a Form  is appropriate, you must complete either Box A (serious harm test) or Box B

(persons who are incapable of consenting to treatment and meet the specied criteria test) below.

Box A – Section () of the Mental Health Act

Serious Harm Test

The Past / Present Test (check one or more)

I have reasonable cause to believe that the person:

 has threatened or is threatening to cause bodily harm to himself or herself

 has attempted or is attempting to cause bodily harm to himself or herself

 has behaved or is behaving violently towards another person

 has caused or is causing another person to fear bodily harm from him or her; or

 has shown or is showing a lack of competence to care for himself or herself

I base this belief on the following information (you may, as appropriate in the circumstances,

rely on any combination of your own observations and information communicated to you by

others.)

My own observations:

Facts communicated to me by others:

The Future Test (check one or more)

I am of the opinion that the person is apparently suering from mental disorder of a nature

or quality that likely will result in:

 serious bodily harm to himself or herself,

 serious bodily harm to another person,

 serious physical impairment of himself or herself