Government of Ontario: Ministry of Health

Form 4 Mental Health Act
Certificate of Renewal

Name of patient (print name of patient)

Name of physician (print name of physician)

Name of psychiatric facility (if applicable) (name of psychiatric facility)

Date of examination (date)

The person's status at the psychiatric facility is that he/she is

an involuntary patient subject to a Certificate of Involuntary Admission which expires on (date) or
an involuntary patient subject to an existing Certificate of Renewal which expires on (date)

You must complete one or more of Box A or Box B for this form to be valid.

Box A

You must be satisfied that both criteria are met.

I am of the opinion that

1. The patient is suffering from mental disorder of a nature or quality that likely
will result in: (choose one or more of the following)

serious bodily harm to the patient,
serious bodily harm to another person,
serious physical impairment of the patient,

unless he or she remains in the custody of a psychiatric facility

2. The patient is not suitable for continuation as an informal or voluntary patient.

Box B

You must be satisfied that all six criteria are met.

I am of the opinion that

1. the patient has been found 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,

AND

2. the patient has previously received treatment for mental disorder of an
ongoing or recurring nature that, when not treated, is of a nature or quality
that likely will result in (choose one or more of the following)

serious bodily harm to the patient,
serious bodily harm to another person,
substantial mental or physical deterioration of the patient, or
serious physical impairment of the patient,

AND

3. has shown clinical improvement as a result of the treatment,

AND

4. is 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,

AND

5. given the patient'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,
cause serious bodily harm to another person,
suffer substantial mental or physical deterioration,
suffer serious physical impairment;

AND

6. the patient is not suitable for continuation as an informal or voluntary patient.

This is a Certificate of Renewal.

This certificate is effective on the date that it is signed and expires on
(Date) (day / month / year)

(Date of signature)

_________________________________________(signature of attending physician)

(Disponible en version française)

6430-41 (00/12)
7530-4975

Government of Ontario: Ministry of Health

Form 4 Mental Health Act Certificate of Renewal

Form 4 Mental Health Act
Certificate of Renewal