Gouvernement de l'Ontario: Ministry of Health

Form 33
Mental Health Act
Notice to Patient under Subsection 59(1) of the Act and under Clause 15(1) (a) and 15.1(a) of Regulation 741

To: (print name of patient)

of (home address)

This is to inform you that on (date of determination)

I,(print name of physician) , have made a determination that you

Check appropriate box(es):
1. are not mentally capable to consent to the collection, use or disclosure of personal health information within the meaning of the Personal Health
Information Protection Act, 2004 (Patient uses Form P-1 to challenge findings)
2. are not mentally capable to manage your property (Patient uses Form 18 to challenge findings)
3. are not mentally capable to consent to treatment of a mental disorder ("treatment" within the meaning of the Health Care Consent Act) (Patient uses Form A to challenge findings)

Check where appropriate:
1. A certificate of incapacity to manage property has been issued (Patient uses Form 21 to challenge findings)
2. A certificate of continuance has been issued (Patient uses Form 24 to challenge findings)

If you wish to challenge this (these) determination(s), you have the right to a hearing before the Board. You may apply for a hearing by completing the relevant form noted above.

Application forms are available from a Rights Adviser, this facility and the regional offices of the Board.

(date)

(signature of physician)

(print name of physician)

(print name of psychiatric facility)

After you receive this notice, a person called a "rights adviser" will meet with you to inform you as to your rights and help you in applying for a hearing if that is what you wish to do.

For further information or assistance with anything mentioned in this notice, please contact

(print name(s) of appropriate staff member(s))

(telephone number)

(print name of psychiatric facility)

Note: The physician shall promptly notify a rights adviser.

(date and time rights adviser notified)

(Disponible en version française)

1088-41 (2022/11)

7530-4324

Gouvernement de l'Ontario: Ministry of Health

Form 33 Mental Health Act Notice to Patient under Subsection 59(1) of the Act and under Clause 15(1) (a) and 15.1(a) of Regulation 741

Form 33
Mental Health Act
Notice to Patient under Subsection 59(1) of the Act and under Clause 15(1) (a) and 15.1(a) of Regulation 741