Government of Ontario: Ministry of Health

TO:

Name of person (type in full)

WHEREAS I have reasonable cause to believe that the above person may come or be brought into Ontario from:

and that the above person is suffering from mental disorder of a nature or quality that likely will result in:

a) serious bodily harm to the person, or
b) serious bodily harm to another person,

unless the person is placed in the custody of a psychiatric facility,

I therefore order you to take the above person to

(name of psychiatric facility)

(Minister of Health and Long-Term Care)

Date (day / month / year)