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Manitoba MHA Form 5: Voluntary to Involuntary Status

When a voluntary patient in a Manitoba psychiatric facility appears to meet the criteria for an involuntary psychiatric assessment, the attending physician uses this application to ask the medical director to change the patient's status. It records the examination date, the criteria the physician believes are met and the supporting facts, and starts the clock on a psychiatrist's assessment.

Who completes it

The attending physician of the voluntary patient completes and signs the whole form after personally examining the patient. The psychiatrist who then assesses the patient completes a Form 6 if the involuntary admission requirements are met.

Submitting and payment

How to submit it
The application is filed with the medical director of the facility. The printed copy line sends the original to the medical director, one copy to the patient's chart and one to the Director of Psychiatric Services.

Good to know

  • Under section 6, a psychiatrist must assess the patient within 72 hours after the application, or within 24 hours if the person has already been a patient for more than 72 hours.
  • The physician checks at least one risk box (serious harm to self or to another person, or substantial mental or physical deterioration) and states the patient refuses or cannot competently consent to assessment.
  • On competence, the form states the physician considered whether the patient understands the nature and purpose of an assessment and can appreciate the consequences of giving or withholding consent.
  • When status changes, the medical director must promptly tell the patient in writing, including the right to apply to the Mental Health Review Board and to retain and instruct counsel.

Get the official form

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

Form 5 - Application by Attending Physician for Change of Patient's Status from Voluntary to Involuntary

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

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

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Frequently asked questions

When is Form 5 used instead of Form 4?

Form 5 is for a person who is already a voluntary patient in the facility, and only the attending physician files it. Form 4 is used by a qualified health professional for a person who is not yet a patient. Both lead to a psychiatrist's assessment and, if the criteria are met, a Form 6 Involuntary Admission Certificate.

What happens after a Form 5 is filed?

A psychiatrist must assess the patient within 72 hours, or within 24 hours if the patient has been in the facility for more than 72 hours. If the psychiatrist finds the subsection 17(1) requirements met, they complete an involuntary admission certificate and file it with the medical director.

Is Form 5 available in French?

Yes. Form 5 is a single bilingual form; the French title is Formule 5, Demande visant le placement en cure obligatoire d'un malade en cure volontaire. CPSM relayed a notice that copies printed from the internet are not legally valid, so prescribed forms come from the Office of the Chief Provincial Psychiatrist.