A Yukon physician completes this Mental Health Act form after examining a person to assess their mental condition under sections 5 and 10 of the Act. The physician records the examination findings, any prior knowledge and behaviour reported by others, then chooses release or recommends involuntary psychiatric assessment at a named designated facility. A recommendation lets the person be taken to hospital for examination by two physicians.
The examining physician completes and signs the whole form, and a witness signs below. Yukon posts a separate form for a nurse who makes the same recommendation, and the Act requires that nurse to consult a physician.
Download the current version from the source each time; forms change without notice.
Form 4 - Recommendation for Involuntary Psychiatric Assessment (Physician)
Formulaire 4 - Recommandation d'évaluation psychiatrique non volontaire (médecin)
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Section 11 of the Mental Health Act makes the recommendation sufficient authority for a peace officer or other person to take the person into custody as soon as possible, and no later than the end of the sixth day after the day it was made. The person can then be detained and observed in hospital for up to 24 hours.
The form asks for the affective, cognitive and behavioural presentation at examination, including appearance, speech, thought content, insight, judgment and diagnosis. Separate sections cover the physician's prior knowledge of the patient and behaviour observed by others, naming the source, the observer, the timing and what was seen. An admitting history can be appended.
Yes. Yukon posts a French version, Formulaire 4, Recommandation d'évaluation psychiatrique non volontaire (médecin), on its French forms page. Both versions are three-page fillable PDFs; the English edition is dated July 2019 and the French edition September 2019.