Government of Ontario: Ministry of Health

To (print name of the child between 12 and 15 years of age inclusive who is an informal patient)

Date of birth, where available

Home Address

This is to inform you that as a child between 12 and 15 years inclusive who is an informal patient in

Print name of psychiatric facility

You, or someone on your behalf, have the right to apply to the Board under section 13 of the Mental Health Act. You may apply for such a hearing by completing Form 25 (attached)

Upon such application, an inquiry as to whether you need to stay in this psychiatric facility for observation, care and treatment will be held.

Date

Signature of Officer in Charge

Print name of Officer in Charge

After you receive this notice, a person called a rights adviser shall meet with you to inform you as to your rights and help you in applying for a hearing if that is what you wish to do.

For further information or assistance with anything mentioned in this notice, please contact

Print name(s) of appropriate staff member(s)

Telephone #

Note: The Officer-in-charge shall promptly notify a rights adviser.