Form 42 - Notice To Person Under Subsection 38.1 Of The Act Of Application For Psychiatric Assessment

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Form 42
Ministry
Notice to Person under Subsection 38.1 of
the Act of Application for Psychiatric
Mental Health Act
of
Assessment under Section 15 or an Order
Health
under Section 32 of the Act
Clear Form
Part I (complete only if appropriate)
To:
(name of person)
of
(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
threatened or attempted or are threatening or attempting to cause bodily harm to yourself;
Box(es)
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:
Check
serious bodily harm to yourself;
Box(es)
serious bodily harm to another person; or
serious physical impairment of you.
Part B
That physician has certified that he/she has reasonable cause to believe that you:
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
serious bodily harm to yourself,
serious bodily harm to another person,
substantial mental or physical deterioration of you, or
serious physical impairment of you;
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 française)
See reverse
1787–41 (00/12)*
7530–4627

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