Psychiatric Patient Advocate Office - Services

All Forms & Uses

Index of Forms

Under the
Mental Health Act,
Health Care Consent Act, and the
Substitute Decisions Act

Forms Under the Mental Health Act

Form #	Form Name	Section of the MHA	Who Signs	When	Expiration Date
1	Application by Physician for Psychiatric Assessment	15	Physician who has examined the person	Within seven days from and including the examination date	Seven days from and including date signed
2	Order for Examination	16	Justice of the Peace	No statutory time restriction	Seven days from and including the day it is signed
3	Certificate of Involuntary Admission	20(1)(c)	Attending physician (different than the physician who completed Form 1)	Within 72 hours from start of detention period under a Form 1 or Form 13	Two weeks from and including the date signed
		19	Attending physician	At any time to change the status of an informal or voluntary patient to involuntary	Two weeks from and including the date signed
4	Certificate of Renewal	20(4)	Attending physician	Before expiry date of previous Form 3 or 4	1^st Certificate of Renewal: one month from expiry date of preceding Form 3 2^nd Certificate of Renewal: two months from expiry date of preceding Form 4 3^rd & subsequent Certificates of Renewal: three months from expiry date of preceding Form 4
5	Change from Involuntary to Informal or Voluntary Status	20(7)	Attending physician (the physician must specify the reasons for the change of status)	Wherever deemed appropriate	Not applicable
6	Order for Attendance for Examination	21(1)	Judge	When a person appears before a judge charged with or convicted of an offence	No statutory time restriction
7	Confirmation By Attending Physician of Continued Involuntary Status	48 (12)	Attending physician	After an appeal to a court of a board decision is launched (refer to subsection 48(12) for details)	Refer to subsection 48(12)
8	Order for Admission	22(1)	Judge	When a person in custody appears before a judge charged with an offence and the judge has reason to believe that the person suffers from a mental disorder.	No statutory restriction on time within which an order must be executed. Once executed, it authorizes detention for up to two months.
9	Order for Return	28(1)	Officer in charge of psychiatric facility	When the absence of a person who is subject to detention becomes known to the officer in charge.	One month after absence became known to officer in charge
10	Memorandum of Transfer	29(1)	Officer in charge of psychiatric facility	At any time, on advice of attending physician	No statutory time restriction
11	Transfer to a Public Hospital	30(1)	Officer in charge of psychiatric facility	At any time when patient requires hospital treatment that cannot be supplied in the psychiatric facility	No statutory time restriction. If involuntary patients are transferred, detention is subject to limitations on certificates.
12	Warrant for Transfer from Ontario to another Jurisdiction	31	Minister of Health and Long-Term Care	No statutory time restriction	No statutory time restriction
13	Order to Admit a Person Coming into Ontario	32	Minister of Health and Long-Term Care	No statutory time restriction	No statutory restriction on time within which order must be executed
15	Statement by Attending Physician	35(6)	Attending physician	When disclosure required by Court or under an Act and certain conditions exist	No statutory time restriction
16	Application to the Consent and Capacity Board to Review a Patient's Involuntary Status	39(1)	Involuntary patient or anyone on his or her behalf; Minister of Health and Long-Term Care, Deputy Minister, officer in charge	Refer to s. 39(2)	No statutory time restriction
17	Notice to the Consent and Capacity Board of the Need to Schedule a Mandatory Review of a Patient's Involuntary Status	39(4)	Officer in charge of psychiatric facility	On completion of every fourth certificate of renewal	Not applicable
18	Application to the Board to Review a Finding of Incapacity to Manage Property	60	Patient or outpatient	Any time after certificate of incapacity or notice of continuance is issued (once in any 6-month period)	No statutory time restriction
21	Certificate of Incapacity to Manage One's Property	54(4)	Physician who performs the examination under section 54(1) or 54(2) with regard to a person who is a patient in a psychiatric facility under the Mental Health Act	No statutory time restriction	On discharge from the psychiatric facility unless a Form 24 is signed within twenty-one days before discharge
22	Financial Statement	55	Officer in charge	As soon as possible after the Public Trustee becomes the patient's statutory guardian	Not applicable
23	Notice of Cancellation of Certificate of Incapacity to Manage One's Property	56	Physician who performs the examination	No statutory time restriction	No statutory time restriction
24	Notice of Continuance of Certificate of Incapacity to Manage One's Property	57(2)	Physician who performs the examination	Within 21 days before the patient's discharge	Indefinite
25	Application to the Consent and Capacity Board to Review the Status of an Informal Patient who is a Child between 12 and 15 Years of Age	13(1)	Young person between 12 and 15 years of age inclusive	Right to apply once every 3 months	No statutory time restriction
26	Notice to the Board of Need to Schedule a Mandatory Review of the Status of an Informal Patient who is a Child between 12 and 15 Years of Age	13(2)	Officer in charge of psychiatric facility	Six months after admission as an informal patient or the young person's last Form 25 application	Not applicable
27	Notice by Officer in Charge to an Informal Patient between 12 and 15 Years old	38(6)	Officer in charge of psychiatric facility	Upon admission	Not applicable
30	Notice to Patient	38(1))	Attending physician	When the patient is put on a Form 3 (Involuntary admission) or a Form 4 (Renewal)	Not applicable
33	Notice to Patient	38(4) 59(1) and Section 15(1) of the regulations	Physician who makes determination	When a physician determines that a patient is not mentally competent to (a) consent to treatment; (b) examine or authorize disclosure of his/her clinical record; or (c) manage his/her property	Not applicable
42	Notice to Person under ss 38.1 of the Act of Application for Psychiatric Assessment under s. 15 or an Order under s. 32 of the Act	38.1	Attending physician	Promptly when a person is detained at a psychiatric facility for the purpose of an assessment under a Form 1 or a Form 13	Not applicable
45	Community Treatment Order	33.1	Physician qualified to issue or renew a community treatment order	No statutory time restriction. Examination within 72 hours as precondition for issuing CTO	6 months
46	Notice to Person of Issuance or Renewal of Community Treatment Order	33.1(10)	Physician who issued or renewed the community treatment order	No statutory time restriction. Examination within 72 hours as precondition for issuing CTO	Not applicable
47	Order for Examination	33.3	Physician who issued or renewed the community treatment order	Authority for 30 days after issue for a police officer to take the person named in it into custody and then promptly to a physician	30 days
48	Application to Board to Review Community Treatment Order and Notice to Board by Physician of Need to Schedule Mandatory Review of Community Treatment Order	39.1(1) and 39.1(4)	Person subject to a CTO or a person on his or her behalf or the Physician who issued or renewed the CTO	A person subject to a CTO (or another person on his or her behalf) may apply each time a CTO is issued or renewed. The issuing physician must provide notice to the Board of a mandatory hearing each time a CTO is renewed for the second time and on every second renewal thereafter.	Not applicable
49	Notice of Intention to Issue or Renew Community Treatment Order	33.1(4) and 33.1(8)	Physician who issued or renewed the community treatment order	No statutory time restriction. Examination within 72 hours as precondition for issuing CTO	Not applicable
50	Confirmation of Rights Advice	14.3 (5) 14.3 (6) 16 (2) of the Regulations	Rights adviser	No statutory time restriction. Completed where a rights adviser is required to explain a matter to a person under the act	Not applicable

Forms Under the Health Care Consent Act

Form letter	Form Name	Section of the HCCA	Who Signs	When
A	Application to the Board to Review a Finding of Incapacity	32(1) 50(1) 65(1)	Person determined to be incapable	When a finding is made that a person is incapable of making decisions with respect to treatment, admission to a care facility or personal assistance services in a nursing home or home for the aged
B	Application to the Board to Appoint a Representative	33(1) 51(1) 66(1)	Person determined to be incapable	When a finding is made that a person is incapable of making decisions with respect to treatment, admission to a care facility or personal assistance services in a nursing home or home for the aged
C	Application to the Board to Appoint a Representative	33(2) 51(2) 66(2)	Anyone who is at least 16 years of age and wishes to be appointed as the representative for a person who has been determined to be incapable	When a finding is made that a person is incapable of making decisions with respect to treatment, admission to a care facility or personal assistance services in a nursing home or home for the aged
D	Application to the Board for Directions	35(1) 52(1) 67(1)	Substitute decision-maker or health care practitioner	The substitute decision-maker or health care practitioner requests assistance because a prior wish of the incapable person is not clear or it is not clear if the wish: - was expressed when the person was capable and at least 16 years old, or - is applicable in the circumstances.
E	Application to the Board for Permission to Depart from Wishes	36(1) 53(1) 68(1)	Substitute decision-maker or health care practitioner	When the prior capable wishes require the substitute decision-maker to refuse treatment, admission or personal assistance services The application may only be granted if the Board finds that the incapable person, if capable, would probably consent because the likely result is significantly better than would have been anticipated in comparable circumstances at the time the wish was expressed.)
F	Application to the Board for Review of Someone Else's Decision to Consent to Admission for the Purpose of Treatment	34(1)	Patient	When a health practitioner has made a finding of incapacity to consent to treatment and the substitute decision-maker has consented to the admission
G	Application to the Board to Review Compliance with Rules for Substitute Decision-Making	37(1) treatment)	Health practitioner who proposed the treatment	When the applicant is of the opinion that the substitute decision-maker has given or refused consent in a manner that violates the rules for substitute decisions found in the Act
G	(cont'd)	54(1) admission to a nursing home or home for the aged)	Official of the Community Care Access Centre responsible for authorizing the admission	When the applicant is of the opinion that the substitute decision-maker has given or refused consent in a manner that violates the rules for substitute decisions found in the Act
G	(cont'd)	69(1) personal assistance services in a nursing home or home for the aged)	Member of the service providers staff responsible for the personal assistance service	When the applicant is of the opinion that the substitute decision-maker has given or refused consent in a manner that violates the rules for substitute decisions found in the Act
H	Application to Amend the Conditions of the Appointment of a Representative	33(7) 51(6) 66(6)	Any person	At any time after the Board has appointed a representative to make decisions on behalf of an incapable person with respect to treatment, admission to a care facility or personal assistance services in a nursing home or home for the aged
	Or Application to Terminate the Appointment of a Representative	33(8) 51(6) 66(6)

Forms Under the Substitute Decisions Act

Form #	Form Name	Section of the SDA	Who Signs	When
1	Application to Replace the Public Guardian and Trustee as Statutory Guardian	17(1)	Person wishing to become the statutory guardian	At any time after a statutory guardianship is created
2	Management Plan	17(3) 70 (1)(b)	Person wishing to become the statutory guardian or court-appointed guardian of property	When making an application to replace the Public Guardian and Trustee as statutory guardian (Form 1) or an application to the court to be named as the guardian of property for an incapable person or at any other time when a management plan for property is required
3	Guardianship Plan	70(2)(b)	Proposed guardian for personal care	When making an application to the court to be named as guardian of the person for an incapable person or at any other time when a management plan for personal care is required
4	Request for Assessment of Capacity	16(1)	Any person	At any time when the applicant has reason to believe that a person may be incapable of managing property. Prior to signing, the applicant must make reasonable inquiries and satisfy him- or herself that no spouse, partner or relative intends to apply to the court for the appointment of a guardian of property and that there is no continuing power of attorney that gives the attorney authority over all of the person's property.
5	Statement Required Under Paragraph 1 of Section 50(1) of the Act	50(1)	Person making a power of attorney for personal care under section 50 of the Act (Ulysses Contract)	At the time that the power of attorney for personal care under section 50 of the Act (a Ulysses Contract) is executed or within 30 days afterwards
6	Optional Statement to Appoint a Guardian of the Person	71(1)	A person making application to the court for the appointment of a guardian of the person	At the time that the application to appoint a guardian of the person is made to the court
7	Optional Statement to Terminate Guardianship of the Person	71(2)	Person asking the court to terminate guardianship of the person	At the time that the motion to terminate the guardianship of the person is made to the court
8	Statement of a person who is not an Assessor under Section 72 of the Substitute Decisions Act	72	Person who knows the person alleged to be incapable and has been in personal contact with him or her during the last twelve months	At the time that an application to the court is made by way of summary disposition for the appointment of a guardian of property Summary disposition means that the judge is asked to decide the matter based on the information in the court file instead of holding a session in open court.)
9	Statement of a Person who is not an Assessor under Section 73 of the Substitute Decisions Act	73	Person who knows the person whose property is under guardianship and has been in personal contact with him or her during the last twelve months	At the time that a motion is brought before the court to terminate a guardianship of property
18 sda	Application to the Board for a Review of a Finding of Incapacity to Manage Property	20.2(1)	Person found to be incapable of managing property and who under statutory guardianship	At any time. An application may only be made once within a six-month period. A reassessment may be required prior to application being made.

The Mental Health Act and the Health Care Consent Act, 1996 provide for the use of prescribed forms, approved by the Lieutenant Governor in Counsel. In addition, Bill 68 permits the Minister of Health and Long-Term Care to approve forms for use under its provisions. The full-text version of the above forms can be found as below:

Mental Health Act forms: Ministry of Health and Long Term Care Link.

Health Care Consent Act forms: Consent and Capacity Board Link.