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Manitoba MHA Form 4: Involuntary Psychiatric Assessment

A physician, or an authorized physician assistant or clinical assistant, uses this Manitoba Mental Health Act application after examining a person who appears to meet the section 8 criteria. It is addressed to the medical director of a designated facility and, once signed, authorizes a peace officer to take the person into custody, detention and observation for up to 72 hours, and a psychiatrist's assessment of whether involuntary admission is needed.

Who completes it

The qualified health professional who examined the person completes and signs the whole form and states their profession. The Act defines that as a physician, or a physician assistant or clinical assistant authorized under the College of Physicians and Surgeons of Manitoba General Regulation.

Submitting and payment

How to submit it
The application goes to the medical director of the facility named at the top and must be made within two days after the examination. The printed copy line sends the original to the medical director and copies to the applicant, the facility chart and the Director of Psychiatric Services.

Good to know

  • The form requires the opinion that a mental disorder makes the person likely to seriously harm themselves or others or to deteriorate substantially, and that they refuse or cannot competently consent to a voluntary assessment.
  • Under subsection 8(1.1), now printed in the form's notes, the examination may be done without being in the person's presence when an in-person examination is not reasonably practicable, subject to the regulations.
  • The applicant must separate facts they observed from facts communicated by others, and confirm they inquired carefully into the facts needed to form the opinion.
  • CPSM relayed the Chief Provincial Psychiatrist's notice that downloaded forms are not legally valid; the one exception is an urgent Form 4 in an emergency with no prescribed form at hand.

Get the official form

Download the current version from the source each time; forms change without notice.

Form 4 - Application for Involuntary Psychiatric Assessment

Formule 4 - Demande d'évaluation psychiatrique obligatoire

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can sign a Manitoba Form 4?

A qualified health professional as defined in The Mental Health Act: a physician, or a physician assistant or clinical assistant authorized under the College of Physicians and Surgeons of Manitoba General Regulation to examine a person and apply under section 8. If a psychiatrist makes the application, a different psychiatrist must conduct the assessment.

How long is a Manitoba Form 4 valid?

The application must be made within two days after the examination. Once signed, the authority for a peace officer to take the person into custody expires at the end of the seventh day after signing, and the person may be detained, restrained and observed in a facility for not more than 72 hours.

Where do I get an official Form 4?

The regulation's web page posts Form 4 as a bilingual English and French PDF, but CPSM relayed a notice from the Office of the Chief Provincial Psychiatrist saying online copies are for information only. Printed form sets are available on request from the Director of Psychiatric Services, the same office.