Government of Ontario: Ministry of Health

In the (name of court)

held at (address)

TO (name of psychiatric facility)

WHEREAS (name of person in full)

(address)

Strike out inapplicable words

[ is charged with / has been convicted of ]

(offence)

contrary to section

of the
;

AND WHEREAS he/she has appeared before me and I have reason to believe that he/she suffers from mental disorder;

AND WHEREAS I have ascertained from (name of senior physician, as defined in the Act)

the senior physician of (name of psychiatric facility)

that the services of the said psychiatric facility are available to the above-named person;

I HEREBY ORDER that the above-named person attend, by appointment, the said psychiatric facility for examination;

(Judge)

Date (day / month / year)