Government of Ontario: Ministry of Health

Form 47 Mental Health Act
Order for Examination Sections 33.3(1) and 33.4 (3) of the Act

To the police officers of Ontario

WHEREAS

of

is subject to a community treatment order issued or renewed on

by

of
and

WHEREAS such person has



to review his/her condition,

in accordance with ss.33.4 (2) of the Mental Health Act; and

WHEREAS I have reasonable cause to believe that such person

(i) is suffering from mental disorder such that he/she needs continuing treatment or care and continuing supervision while living in the community;

(ii) meets the criteria for the completion of a Form 1 [an application for psychiatric assessment under ss.15 (1) or (1.1) of the Mental Health Act] and is not currently a patient in a psychiatric facility; and

(iii) if the person does not receive continuing treatment or care and
continuing supervision while living in the community, he/she is likely,
because of mental disorder, to (choose one or more of the following)




Order for Examination

Now therefore, I hereby issue this Order for Examination for any of you to take such person in custody forthwith to

for an examination by me or by a physician named below appointed to carry out this responsibility in accordance with ss. 33.5 (2) of the Mental Health Act.

This order is in force for 30 days after the date upon which it is issued and will expire at midnight on

Dated at
on



Notes:

1. The physician who issues an order for examination shall ensure that the police have complete and up-to-date information about the name, address and telephone number of the physician responsible for completing the examination required under an order for examination and shall ensure that the police have such information at all times that the order for examination is in force.

2. The physician who issues an order for examination shall ensure that the police are immediately notified if the person who is subject to the order for examination voluntarily attends for an examination or, for any other reason, the order for examination is cancelled prior to its expiry date.

3. The police may need a physical description of the person named in your Order for Examination so that the person may be located and returned to you for an examination. Please use the space below to provide the police with relevant information about the person's physical description.

4. The police may ask you for information about the person's physical description, in addition to the information you have provided below.

3761–41 (00/12)

7530–5577