Name of physician (print name of physician)
Physician address (address of physician)
Telephone number
Fax number
On (date)
I personally examined (print full name of person)
whose address is (home address)
You may only sign this Form 1 if you have personally examined the person within the past seven days. In deciding if a Form 1 is appropriate, you must complete either Box A (serious harm test) or Box B (persons who are incapable of consenting to treatment and meet the specified criteria test) below.
The Past / Present Test (check one or more)
I base this belief on the following information (you may, as appropriate in the circumstances, rely on any combination of your own observations and information communicated to you by others.)
My own observations:
Facts communicated to me by others:
The Future Test (check one or more)
serious bodily harm to himself or herself, serious bodily harm to another person, serious physical impairment of himself or herself
I base this opinion on the following information (you may, as appropriate in the circumstances, rely on any combination of your own observations and information communicated to you by others.)
I have reasonable cause to believe that the person:
serious bodily harm to himself or herself, serious bodily harm to another person, substantial mental or physical deterioration of himself or herself, or serious physical impairment of himself or herself;
AND
2. Has shown clinical improvement as a result of the treatment. AND I am of the opinion that the person, 3. Is incapable, within the meaning of the Health Care Consent Act, 1996, of consenting to his or her treatment in a psychiatric facility and the consent of his or her substitute decision-maker has been obtained;
4. Is apparently suffering from the same mental disorder as the one for which he or she previously received treatment or from a mental disorder that is similar to the previous one;
5. Given the person's history of mental disorder and current mental or physical condition, is likely to: (choose one or more of the following) cause serious bodily harm to himself or herself, or cause serious bodily harm to another person, or suffer substantial mental or physical deterioration, or suffer serious physical impairment
Facts communicated by others:
I have made careful inquiry into all the facts necessary for me to form my opinion as to the nature and quality of the person's mental disorder. I hereby make application for a psychiatric assessment of the person named.
Today's date
Today's time
Examining physician's signature (signature of physician)
This form authorizes, for a period of 7 days including the date of signature, the apprehension of the person named and his or her detention in a psychiatric facility for a maximum of 72 hours.
Once the period of detention at the psychiatric facility begins, the attending physician should note the date and time this occurs and must promptly give the person a Form 42.
(Date and time detention commences)
(signature of physician)
(Date and time Form 42 delivered)
(Disponible en version française)
6427–41 (00/12) 7530–4972