Government of Ontario: Ministry of Health

To:

AND TO all or any Police Officers in the Province of Ontario.

WHEREAS (print full name of patient)

is subject to detention as

and is absent from (name of psychiatric facility)

AND WHEREAS the absence of such person without authorization became known to me on (date)
.

NOW THEREFORE I hereby direct and authorize you, or any of you, to return such person to the said psychiatric facility or to the psychiatric facility nearest to the place where such person is apprehended;

AND in the course of returning such person, you are authorized to detain such person in an appropriate place.

THIS ORDER shall have force until (date)
.

(Officer-in-Charge)

(print name of Officer-in-Charge)

(psychiatric facility)

Date (day / month / year)