Get Form 42

Ministry of Health Form 42 Mental Health Act Notice to Person under Subsection 38. 1 of the Act of Application for Psychiatric Assessment under Section 15 or an Order under Section 32 of the Act Clear Form Part I complete only if appropriate To name of person home address This is to inform you that name of physician examined you on and has made an application for you to date of examination day / month / year have a psychiatric assessment. Part A and/or Part B must be completed Part A That physician has certified that he/she has reasonable cause to believe that you have Check Box es threatened or attempted or are threatening or attempting to cause bodily harm to yourself behaved or are behaving violently towards another person or have caused or are causing another person to fear bodily harm from you or shown or are showing a lack of competence to care for yourself* and that you are suffering from a mental disorder of a nature or quality that likely will result in serious bodily harm to yourself serious physical impairment of you. Part B a have previously received treatment for mental disorder of an ongoing or recurring nature that when not treated is of a nature or quality that likely will result in substantial mental or physical deterioration of you or b have shown clinical improvement as a result of the treatment c are suffering from the same mental disorder as the one for which you previously received treatment or from a mental disorder that is similar to the previous one Disponible en version fran aise 1787 41 00/12 See reverse 7530 4627 Part B continued d given your history of mental disorder and current mental or physical condition you are likely to cause serious bodily harm to yourself suffer substantial mental or physical deterioration or suffer serious physical impairment e have been found incapable within the meaning of the Health Care Consent Act 1996 of consenting to your treatment in a psychiatric facility and the consent of your substitute decision-maker has been obtained and f you are not suitable for admission or continuation as an informal or voluntary patient. The application is sufficient authority to hold you in custody in this hospital for up to 72 hours. You have the right to retain and instruct a lawyer without delay. date signature of attending physician name of Minister of Health and Long-Term Care Minister of Health and Long-Term Care for the Province of Ontario has reasonable cause to believe that you are suffering from mental disorder of a nature or quality that likely will result in unless you are placed in the custody of a psychiatric facility and has by Order dated authorized your custody in a psychiatric facility for up to 72 hours. Part A and/or Part B must be completed Part A That physician has certified that he/she has reasonable cause to believe that you have Check Box es threatened or attempted or are threatening or attempting to cause bodily harm to yourself behaved or are behaving violently towards another person or have caused or are causing another person to fear bodily harm from you or shown or are showing a lack of competence to care for yourself* and that you are suffering from a mental disorder of a nature or quality that likely will result in serious bodily harm to yourself serious physical impairment of you. Part B a have previously received treatment for mental disorder of an ongoing or recurring nature that when not treated is of a nature or quality that likely will result in substantial mental or physical deterioration of you or b have shown clinical improvement as a result of the treatment c are suffering from the same mental disorder as the one for which you previously received treatment or from a mental disorder that is similar to the previous one Disponible en version fran aise 1787 41 00/12 See reverse 7530 4627 Part B continued d given your history of mental disorder and current mental or physical condition you are likely to cause serious bodily harm to yourself suffer substantial mental or physical deterioration or suffer serious physical impairment e have been found incapable within the meaning of the Health Care Consent Act 1996 of consenting to your treatment in a psychiatric facility and the consent of your substitute decision-maker has been obtained and f you are not suitable for admission or continuation as an informal or voluntary patient.