Gouvernement de l'Ontario: Ministry of Health

Form 42 - Mental Health Act
Notice to Person under Subsection 38.1 of the Act of Application for Psychiatric Assessment under Section 15 or an Order under Section 32 of the Act

Part I (complete only if appropriate)

To: (name of person)

of (home address)

This is to inform you that (name of physician)

examined you on (date of examination) (day / month / year)

and has made an application for you to have a psychiatric assessment.

Part A and/or Part B must be completed

Part A

That physician has certified that he/she has reasonable
cause to believe that you have (check box(es)):

threatened or attempted or are threatening or attempting to cause bodily harm to yourself;
behaved or are behaving violently towards another person or have caused or are causing another person to fear bodily harm from you; or
shown or are showing a lack of competence to care for yourself.

and that you are suffering from a mental disorder of a
nature or quality that likely will result in (check box(es)):
serious bodily harm to yourself;
serious bodily harm to another person; or
serious physical impairment of you.

Part B

That physician has certified that he/she has reasonable cause to believe that you:

a) have 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

serious bodily harm to yourself,
serious bodily harm to another person,
substantial mental or physical deterioration of you, or
serious physical impairment of you;

b) have shown clinical improvement as a result of the treatment;

c) are suffering from the same mental disorder as the one for which you previously received treatment or from a mental disorder that is similar to the previous one;

d) given your history of mental disorder and current mental or physical condition, you are likely to

cause serious bodily harm to yourself,
cause serious bodily harm to another person,
suffer substantial mental or physical deterioration, or
suffer serious physical impairment;

e) have been found incapable, within the meaning of the Health Care Consent Act, 1996 of consenting to your treatment in a psychiatric facility and the consent of your substitute decision-maker has been obtained; and

f) you are not suitable for admission or continuation as an informal or voluntary patient.

The application is sufficient authority to hold you in custody in this hospital for up to 72 hours.

You have the right to retain and instruct a lawyer without delay.

(date)

(signature of attending physician)

Part II (complete only if appropriate)

To: (name of person)

of (home address)

This is to inform you that (name of Minister of Health and Long-Term Care)

Minister of Health and Long-Term Care for the Province of Ontario, has reasonable
cause to believe that you are suffering from mental disorder of a nature or quality that
likely will result in (check box(es)):
cause serious bodily harm to yourself; or
cause serious bodily harm to another person

unless you are placed in the custody of a psychiatric facility and has by Order dated (date of order) (day / month / year)

authorized your custody in a psychiatric facility for up to 72 hours.

You have the right to retain and instruct a lawyer without delay.

(date)