Government of Ontario: Ministry of Health

In the (name of court)

held at (address)

TO the Peace Officers in the of

AND TO (name of psychiatric facility)

WHEREAS (name of person in full)

(address)

is a person in custody charged with (offence)

contrary to section of the ;

AND WHEREAS he/she has appeared before me and I have reason to believe that he/she suffers from mental disorder;

AND WHEREAS I have ascertained from

(name of senior physician, as defined in the Act)

the senior physician of (name of psychiatric facility)

that the services of the said psychiatric facility are available to the above-named person;

I HEREBY ORDER that the above-named person be remanded for admission as a patient to the said psychiatric facility for a period of not more than ;

AND I FURTHER ORDER and direct you, the said Peace Officers, or any of you, to convey him/her to the said psychiatric facility;

AND I AUTHORIZE you, the authorities at the said psychiatric facility, to admit him/her in accordance with this order.

_______________________________________________(Judge)

Date (day/month/year)