1. Name of patient in full:
3. Psychiatric facility:
4. Residence (street and number or lot and concession):
(Municipality):
(County, etc, or district):
5. Length of residence in this municipality:
6. Date of birth:
7. Place of birth:
8. Citizenship:
9. Occupation:
10. Martial statusl:
11. If married, give name and address of husband or wife:
12. If not married, give name and address of spouse or partner, if applicable:
13. Give the name and address of next of kin:
14. Give the names and ages of any dependants whom the patient has to support:
15. Give patient's:
1. Social Insurance Number:
2. Health Card number
3. If other medical insurance plan, state name of company and contract number
4. Old Age Security Number:
16. Name and address of employer:
17. Property of patient, and mortgages or charges on same, if any:
1. Number of lot, concession, township and county, etc.
2. Number of acres:
3. Leasehold or freehold:
4. Name and address of mortgagee, if any:
5. Market value of property:
18. If property of the patient has been rented, give the following information:
1. Name of tenant:
2. Particulars of tenancy, such as length and terms of lease?:
3. Is the lease in writing?
4. If so, in whose possession is the document?
5. Give the address of such person
6. To whom has the rent been paid?
7. To what date has the rent been paid?
19. Life, accident, disability and income protection insurance
Name of the Company or Society
Number of Policy or Certificate
Amount of insurance
In whose possession is the policy?
Is this group insurance?(state yes or no)
20. Pension or superannuation
If patient receives pension or superannuation, et., give particulars:
21. Cash on hand, in bank accounts and safety deposits:
1. Give name and address of person who is in possession of the case:
2. What is the amount?:
3. If deposited in a bank, give the name and address of the branch:
4. In whose possession is the bank book?:
5. State the amount in the bank account:
6. If joint account, give name and address of joint owner:
7. If patient has a safety deposit box, give the location, name and address of person in possession of the keys:
22. Stocks, bonds and similar investments
Name of security
Par value
In whose possession
23. Personal property(give approximate values)
1. Farm implements
2. Stock in trade:
3. Livestock:
4. Farm produce:
5. Motor vehicles:
6. Other property or income (if any):
24. Money secured by mortgage
1. Give the name and address of the mortgagors who have borrowed money from the patient, setting out in detail separately each mortgage:
2. State in whose possession the mortgages are, and the address of such person:
25. Book debts and promissory notes owing to the patient
1. Give the names and addresses of debtors:
2. State in whose possession the notes are, and the address of such person:
26. Liabilities, if any, other than mortgage debts
yes no
If so, state in whose possession it is, and the address of such person:
If so, state in whose possession it is, and the address of such person.
29. Any other information relevant to the administration of the patient's financial affairs
(signature of the person completing the form)
(print name of the person completing the form)
(address)
(relationship to patient)
Date (day/month/year)
3592-41E (2023/01) © King's Printer for Ontario, 2023