Government of Ontario: Ministry of Health

Part 1 – Notice of Intention to Issue or Renew a Community Treatment Order

TO: (print full name of person)

I am considering issuing or renewing a community treatment order (Form 45) for you.

Part 2 – Capacity to Consent to Treatment Proposed in a Community Treatment Plan

On date ( day / month / year)
a determination was made that you are incapable with respect to giving or refusing consent to a proposed community treatment plan.

Your substitute decision-maker under the Health Care Consent Act is date ( day / month / year)

Your substitute decision-maker will also receive notice that I am considering issuing or renewing a community treatment order for you.

Part 3 – Community Treatment Plan

A community treatment plan must be developed with you or with your substitute decision-maker (where applicable) and any other health practitioners or persons involved in your treatment or care and supervision.

A copy of the community treatment plan developed for you is attached to this notice.

During the 72 hours prior to entering into the community treatment plan, I examined you and am of the opinion that:

1. You are suffering from mental disorder such that you need continuing treatment or care and continuing supervision while living in the community, AND

2. You meet the criteria for the completion of an application for psychiatric assessment, if you are not currently a patient in a psychiatric facility, AND

3. If you do not receive continuing treatment or care and continuing supervision while living in the community, you are likely, because of mental disorder, to cause serious bodily harm to yourself or another person or to suffer substantial mental or physical deterioration of yourself or serious physical impairment of yourself, AND

4. You are able to comply with the community treatment plan contained in the community treatment order, AND

5. The treatment or care and supervision required under the terms of the community treatment order are available in the community.

Part 4 – Rights Advice and Right to Counsel

TO: (print full name of person)

AND TO: (print name of substitute decision-maker, if applicable)

You are entitled to consult a rights adviser before a community treatment order can be issued or renewed.

A rights adviser will receive notice of the physician's intention to issue or renew a community treatment order and will contact you for the purpose of providing you with rights advice.

You have the right to retain and instruct counsel about the proposed community treatment order before it is issued or renewed and to retain and instruct counsel about the community treatment order at any time after it is issued or renewed.

Date of issue (day / month / year)

(physician's business address)

(name of psychiatric facility if applicable)

(signature of physician)

(print name of physician)