To the police officers of Ontario. Whereas information upon oath has been brought before me, a justice of the peace in and for the province of Ontario by (print full name of person bringing information) of (address of person bringing information) in respect of (print full name or other description of person to be examined) of (home address, if known)
Part A or Part B must be completed
has threatened or attempted or is threatening or attempting to cause bodily harm to himself or herself; has behaved or is behaving violently towards another person or has caused or is causing another person to fear bodily harm from him or her; or has shown or is showing a lack of competence to care for himself or herself.
serious bodily harm to the person; serious bodily harm to another person, or serious physical impairment of the person.
Information has been brought before me that such person a) has 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 the person or to another person or substantial mental or physical deterioration of the person or serious physical impairment of the person; and
b) has shown clinical improvement as a result of the treatment;
In addition based upon the information before me I have reasonable cause to believe that the person,
c) is apparently suffering from the same mental disorder as the one for which he or she previously received treatment or from a mental disorder that is similar to the previous one;
cause serious bodily harm to himself or herself; cause serious bodily harm to another person, suffer substantial mental or physical deterioration of the person , or suffer serious physical impairment of the person; and
e) is apparently incapable within the meaning of the Health Care Consent Act, 1996 of consenting to his or her treatment in a psychiatric facility and the consent of his or her substitute decision-maker has been obtained.
Now therefore, I order you, the said police officers, or any of you, to take the said person in custody forthwith to an appropriate place for examination by a physician.
(date of signature) (Municipality where order signed) (print name of Justice of the Peace)
______________________________________(signature of Justice of the Peace)
1. You may wish to provide your telephone number on this form so that you can be contacted by the police or the examining physician after this order is issued. This is entirely voluntary. You are not required to give this information for the order to be issued or for the order to be legally valid.
(print name) (telephone number)
2. You may wish to seek legal advice concerning this order, including the effect of this order and your legal rights.
3. You may wish to inform the police, the examining physician and/or an appropriate health care professional of the evidence you gave to the justice of peace, if you consider it appropriate in all the circumstances to do so. If you decide to do so, please use the space provided below. Use the back of this form if necessary. You are not required to give this information for the order to be issued or for the order to be legally valid.
6428-41 (00/12) 7530-4973