Mental Health Act forms for involuntary assessment and admission

First medical certificate under section 22 of the BC Mental Health Act: authorizes apprehension and conveyance to a designated facility (valid up to 14 days from the assessment when completed outside one) and, once the MHA director or delegate completes Section 2, involuntary admission for up to 48 hours.

Completed by

Physician or nurse practitioner who examined the person (MHA director or delegate of the designated facility completes Section 2)

Issued by

BC Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Second medical certificate under section 22 of the BC Mental Health Act, completed within 48 hours of admission, that continues involuntary admission for up to one month from the admission date.

Completed by

Physician other than the physician who completed the first certificate (MHA director or delegate completes Section 2)

Issued by

BC Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Renewal certificate under section 24 of the BC Mental Health Act renewing an involuntary patient's detention for the next period (one month, then three months, then six-month periods) after a physician's examination.

Completed by

Physician who is the director of the designated facility or is authorized by the director (including an authorized community physician for patients on extended leave)

Issued by

BC Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Authorizes release of an involuntary patient on leave under section 37 of the BC Mental Health Act (required unless return is required within 14 days), setting conditions of leave and authorizing a community physician to assume care, renewals, changes to conditions, recall and discharge.

Completed by

Director of the designated facility or a physician authorized by the director (patient signs to confirm conditions were explained; community physician named, advised to sign beside their name)

Issued by

BC Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Admission certificate under section 2 of the Alberta Mental Health Act: one certificate authorizes conveyance to a facility (within 72 hours of issue) and 24 hours of detention for examination; two certificates make the person a formal patient for one month.

Completed by

Physician or other qualified health professional (including a nurse practitioner) who examined the person

Issued by

Alberta Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Renewal certificate under section 8 of the Alberta Mental Health Act; two certificates after separate examinations extend a formal patient's detention by one month, one further month, then up to six months each time.

Completed by

Psychiatrist or other qualified health professional (two certificates: at least one by a psychiatrist and at least one by a member of the facility staff)

Issued by

Alberta Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Prescribed form for two qualified health professionals (one a psychiatrist) to issue a six-month community treatment order under section 9.1 of the Alberta Mental Health Act, with written statement, examinations, treatment and care plan, supervision and consent.

Completed by

Issuing qualified health professional and a second examining qualified health professional, one of whom is a psychiatrist (treatment providers sign Part III, supervising QHP Part IV, person or substitute decision-maker Part V)

Issued by

Alberta Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Prescribed form to renew an Alberta community treatment order for a further six months under section 9.3 of the Mental Health Act after separate examinations by two qualified health professionals, one a psychiatrist.

Completed by

Issuing qualified health professional for the renewal and a second examining qualified health professional, one of whom is a psychiatrist (providers, supervising QHP and person or substitute decision-maker sign their parts)

Issued by

Alberta Health (Mental Health Act forms)

Format

Fillable PDF

Language

English

Certificate under section 18 of The Mental Health Services Act that a person who refuses a psychiatric examination has a mental disorder and needs one, authorizing apprehension and conveyance to a physician with admitting privileges to a mental health centre.

Completed by

Examining physician, or a prescribed health professional (supervised psychiatry resident or qualifying rural RN, RPN or NP) when no physician is available within a reasonable period

Issued by

Saskatchewan Ministry of Health (Mental Health Services Act forms)

Format

Fillable PDF

Language

English

Physician's certificate under section 24 of The Mental Health Services Act for involuntary admission; two certificates (at least one by a psychiatrist) authorize detention until the end of the 21st day, renewable for successive 21-day periods.

Completed by

Physician with admitting privileges to a mental health centre, or a resident in psychiatry supervised by such a psychiatrist (two certificates, at least one by a psychiatrist)

Issued by

Saskatchewan Ministry of Health (Mental Health Services Act forms)

Format

Fillable PDF

Language

English

Psychiatrist's community treatment order under section 24.3 of The Mental Health Services Act (new or renewal), stating the six criteria, services and treatment, authorized persons, any required residence and a period of up to six months.

Completed by

Examining psychiatrist

Issued by

Saskatchewan Ministry of Health (Mental Health Services Act forms)

Format

Fillable PDF

Language

English

Second psychiatrist's certificate under section 24.4 of The Mental Health Services Act confirming the community treatment order criteria and concurring with its treatment and services, which validates a Form H.3 order.

Completed by

A psychiatrist other than the one who issued the order (or a physician designated by the regional director under s.24.31 when no other psychiatrist is reasonably available)

Issued by

Saskatchewan Ministry of Health (Mental Health Services Act forms)

Format

Fillable PDF

Language

English

Formule 4 - Demande d'évaluation psychiatrique obligatoire

Application to a facility's medical director for an involuntary psychiatric assessment of a person who meets the section 8 criteria; authorizes custody, conveyance, up to 72 hours' detention and a psychiatrist's assessment.

Completed by

Qualified health professional: a physician, or a physician assistant or clinical assistant authorized under the CPSM General Regulation (M.R. 163/2018)

Issued by

Manitoba Health (Mental Health Act forms)

Format

PDF

Language

Bilingual

Formule 5 - Demande visant le placement en cure obligatoire d'un malade en cure volontaire

Attending physician's application under section 6 to change a voluntary patient's status to involuntary, triggering a psychiatrist's assessment within 72 hours (24 hours if already a patient over 72 hours).

Completed by

Attending physician of the voluntary patient

Issued by

Manitoba Health (Mental Health Act forms)

Format

PDF

Language

Bilingual

Formule 6 - Certificat d'admission en cure obligatoire

Psychiatrist's certificate admitting a person as an involuntary patient under sections 17 and 18; authority to detain, restrain, observe, examine and treat for up to 21 days.

Completed by

Examining psychiatrist (not the psychiatrist who applied for the assessment)

Issued by

Manitoba Health (Mental Health Act forms)

Format

PDF

Language

Bilingual

Formule 7 - Certificat de renouvellement

Attending psychiatrist's certificate renewing an involuntary patient's status under section 21 for up to three months per renewal.

Completed by

Attending psychiatrist of the involuntary patient

Issued by

Manitoba Health (Mental Health Act forms)

Format

PDF

Language

Bilingual

Formule 1 - Demande d'évaluation psychiatrique faite par un médecin

Physician application authorizing detention for a psychiatric assessment when the Box A (serious harm) or Box B criteria are met.

Completed by

Physician who personally examined the person within the past 7 days

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 3 - Certificat d'admission en cure obligatoire

Attending physician certifies involuntary admission after psychiatric assessment.

Completed by

Attending physician

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Statutory forms for involuntary psychiatric assessment and admission, renewals, status changes, capacity certificates and community treatment orders under the Mental Health Act.

Completed by

Physician (attending physician or physician issuing the CTO)

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Form 42 - Mental Health Act

Written notice to the person that an application for psychiatric assessment (Form 1) or an order under s. 32 has been made.

Completed by

Physician who completed Form 1 (or attending physician)

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 45 - Ordonnance de traitement en milieu communautaire

Issues or renews a community treatment order setting out the community treatment plan and conditions.

Completed by

Physician issuing or renewing the CTO

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 4 - Certificat de renouvellement

Renews involuntary status at the end of a certificate period.

Completed by

Attending physician

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 21 - Cetificat d'incapacité de gestion des biens en vertu du paragraphe 54(4) de la Loi

Physician certifies that a psychiatric-facility patient is not capable of managing their property.

Completed by

Attending physician

Issued by

Ministry of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 1 - Certificat d'examen

Physician's certificate that a person may be suffering from a serious mental illness requiring hospitalization, authorizing custody and transport to a psychiatric facility and up to 72 hours' detention for assessment.

Completed by

Physician practising in New Brunswick who personally examined the person

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 2.1 - Demande d'admission d'une personne à titre de malade en placement non volontaire

Attending psychiatrist's application to a tribunal for an order admitting a person (held on an examination certificate or judge's order, or a voluntary patient) as an involuntary patient, with the examination report.

Completed by

Attending psychiatrist practising in New Brunswick

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 12 - Premier certificat de détention

Attending psychiatrist's certificate continuing an involuntary patient's detention for up to one month after the tribunal order period.

Completed by

Attending psychiatrist (on personal examination)

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 13 - Deuxième certificat de détention

Joint certificate of two psychiatrists continuing an involuntary patient's detention for up to two months after the first certificate expires.

Completed by

Attending psychiatrist and a second psychiatrist, both on personal examination

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 34.I - Demande de plan de soins communautaires supervisés

Psychiatrist's application to the Mental Health Act Review Board for a supervised community care plan, setting out the s.34.01 eligibility criteria, planning meeting, team roles, appointments, medications and housing.

Completed by

Applying psychiatrist (attending psychiatrist if hospitalized, community psychiatrist if not); client signs an acknowledgement; person reviewing the plan with the client signs

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 34.VII - Soins communautaires supervisés - Formule de renouvellement

Psychiatrist's application to the review board to renew a supervised community care plan for one year, confirming the criteria still apply and the plan has demonstrated effectiveness.

Completed by

Applying psychiatrist (individual also signs)

Issued by

New Brunswick Department of Health (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Physician's certificate after a medical examination that a person meets the section 8 criteria; two certificates (or Form 2 plus Form 3) authorize custody, a 72-hour hold and an involuntary psychiatric assessment.

Completed by

Physician who examined the person (two separate physicians, unless Form 3 is used)

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Physician's certificate under subsection 10(2) that compelling circumstances exist and no second physician is readily available, so a single Form 2 is sufficient authority.

Completed by

The same physician who signed the attached Form 2

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Psychiatrist's declaration, after an involuntary psychiatric assessment, admitting a person as an involuntary inpatient under section 17 for up to 30 days.

Completed by

Psychiatrist on the staff of the facility who conducted the involuntary psychiatric assessment

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Attending psychiatrist's declaration renewing an involuntary inpatient's status under section 21 for up to 30, 60 or 90 days.

Completed by

Attending psychiatrist on the staff of the psychiatric facility

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Psychiatrist's community treatment order with the section 48 community treatment plan, valid up to 180 days.

Completed by

Attending psychiatrist (signed in the presence of one subscribing witness)

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Attending psychiatrist's renewal of a community treatment order for 180 days under section 52.

Completed by

Attending psychiatrist (signed in the presence of one subscribing witness)

Issued by

Nova Scotia Health and Wellness (Involuntary Psychiatric Treatment Act forms)

Format

PDF

Language

English

Order under section 8 of PEI's Mental Health Act referring a person a practitioner has examined for an involuntary psychiatric assessment.

Completed by

Medical practitioner or nurse practitioner who personally examined the person

Issued by

PEI Department of Health and Wellness (Mental Health Act forms)

Format

PDF

Language

English

Psychiatrist's certificate under section 10 admitting a person to a psychiatric facility as an involuntary patient for up to 30 days.

Completed by

Psychiatrist who personally assessed the person within the previous 72 hours

Issued by

PEI Department of Health and Wellness (Mental Health Act forms)

Format

PDF

Language

English

Attending psychiatrist's certificate under section 11 continuing an involuntary admission for 30 days, 90 days or 12 months depending on the renewal.

Completed by

Attending psychiatrist who personally assessed the patient within the previous 72 hours

Issued by

PEI Department of Health and Wellness (Mental Health Act forms)

Format

PDF

Language

English

Psychiatrist's community treatment order under section 18, with the community treatment plan attached or written in.

Completed by

Psychiatrist who assessed the person within the previous 72 hours

Issued by

PEI Department of Health and Wellness (Mental Health Act forms)

Format

PDF

Language

English

Responsible psychiatrist's renewal under section 20 of an existing community treatment order.

Completed by

Psychiatrist responsible for the community treatment order

Issued by

PEI Department of Health and Wellness (Mental Health Act forms)

Format

PDF

Language

English

First and second certificates of involuntary admission under section 17; with both completed the person is admitted to a psychiatric unit and may be detained up to 30 days.

Completed by

First certificate: physician or nurse practitioner; second certificate: psychiatrist (or another physician if a psychiatrist is not readily available)

Issued by

NL Health and Community Services (Mental Health Care and Treatment Act forms)

Format

Fillable PDF

Language

English

Attending physician's certificate under section 30 renewing an involuntary patient's status (30, 60, then 90 days per renewal).

Completed by

Attending physician

Issued by

NL Health and Community Services (Mental Health Care and Treatment Act forms)

Format

Fillable PDF

Language

English

Psychiatrist's community treatment order under sections 40 to 42, with notice of rights, transfer of responsibility and the community treatment plan; expires after 6 months unless renewed.

Completed by

Issuing psychiatrist (treatment team members named in the plan also sign)

Issued by

NL Health and Community Services (Mental Health Care and Treatment Act forms)

Format

Fillable PDF

Language

English

Formulaire 4 - Recommandation d'évaluation psychiatrique non volontaire (médecin)

Physician's record of a mental health examination under sections 5 and 10 of the Mental Health Act, ending in release or a recommendation for involuntary psychiatric assessment at a named designated facility.

Completed by

Examining physician (Yukon posts a separate nurse recommendation form)

Issued by

Yukon Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formulaire 7 - Certificat d'admission non volontaire

Certificate by each of two examining physicians admitting a person to hospital as an involuntary patient under sections 12 and 13 of the Mental Health Act.

Completed by

Two physicians, each completing a separate copy within 24 hours of the patient's arrival at hospital

Issued by

Yukon Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formulaire 11 - Certificat de renouvellement d'admission non volontaire

Certificate by the attending physician and one other physician renewing a patient's involuntary admission under section 16(1) of the Mental Health Act.

Completed by

Attending physician and one other physician, each completing a separate copy

Issued by

Yukon Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formulaire 12 - Certificat de changement de statut

Physician certificate revoking a Form 7 or Form 11 so that an involuntary patient becomes a voluntary patient under section 17(2) of the Mental Health Act.

Completed by

Physician (the attending physician under s.17(2) of the Act)

Issued by

Yukon Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 2 - Certificat d'évaluation non volontaire

Health professional's certificate authorizing apprehension and conveyance to a designated facility (up to 7 days) and up to 72 hours of involuntary care, assessment and treatment there.

Completed by

Health professional who examined the person (medical practitioner, nurse practitioner, psychologist or registered nurse allowed to practise in the NWT)

Issued by

NWT Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 3 - Certificat d'admission involontaire

Medical practitioner's certificate admitting a person to a designated facility as an involuntary patient for up to 30 days.

Completed by

Medical practitioner (not the one who issued Form 2)

Issued by

NWT Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 4 - Certificat de renouvellement

Attending medical practitioner's certificate renewing involuntary admission for up to 30 days (first), 60 days (second) or 90 days (third and later).

Completed by

Attending medical practitioner

Issued by

NWT Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French

Formule 22 - Certificat de traitement en milieu communautaire assisté

Attending medical practitioner's certificate letting an involuntary patient live outside the designated facility under a Community Treatment Plan for up to six months.

Completed by

Attending medical practitioner (patient and, if applicable, substitute decision maker also sign)

Issued by

NWT Health and Social Services (Mental Health Act forms)

Format

Fillable PDF

Language

English and French