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)





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)):




and that you are suffering from a mental disorder of a
nature or quality that likely will result in (check box(es)):




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





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




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.



Part II (complete only if appropriate)




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)):



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

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



1787–41 (00/12)*
7530–4627