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NWT Form 4: Renewal Certificate (Mental Health Act)

When an involuntary patient's Form 3 or previous renewal is about to expire and the admission criteria are still met, the attending medical practitioner issues this certificate under the Northwest Territories Mental Health Act. A first renewal lasts up to 30 days, a second up to 60 days, and a third or later renewal up to 90 days, with no limit on the number of renewals.

Who completes it

The attending medical practitioner examines the patient and completes the whole form, ticking which renewal it is and recording the current certificate's issue and expiry, the facts, the diagnosis and the new expiry date.

Submitting and payment

How to submit it
The form is filed with the director of the designated facility where the patient is admitted, with copies to the patient and others listed, and a copy goes to the Director of Mental Health. It must be issued within 72 hours before the current certificate expires.

Good to know

  • The patient must still meet all three involuntary admission criteria: mental disorder, likely serious harm or deterioration or serious physical impairment if not admitted, and unsuitability for voluntary admission.
  • If the criteria are no longer met, the attending medical practitioner cancels the admission with Form 5 instead. A certificate that expires without renewal leaves the patient free to leave.
  • Facility directors must notify the Review Board of involuntary patients who have been admitted for six months without a prior Review Board review.
  • A Form 22 Assisted Community Treatment Certificate is cancelled automatically if the patient stops being under a current admission or renewal certificate.

Get the official form

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

Form 4 - Renewal Certificate

Formule 4 - Certificat de renouvellement

Official pagePDFVersion française

Fill it with Vero

Upload the fillable PDF 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

How long does an NWT renewal certificate last?

The first renewal lasts up to 30 days, the second up to 60 days, and the third and each later renewal up to 90 days. The practitioner writes the length, 30, 60 or 90 days, and the exact expiry date and time on the form.

When can Form 4 be issued?

The form notes that it must be issued within 72 hours before the current Certificate of Involuntary Admission or Renewal Certificate expires. In that window the attending medical practitioner must assess the patient and decide whether the involuntary admission criteria continue to be met.

Is the Renewal Certificate available in French?

Yes. Formule 4, Certificat de renouvellement, is published as a separate French PDF under the same catalogue number, NWT9055, alongside the English fillable version on the Department of Health and Social Services forms page.