Form 4 Declaration Of Involuntary Admission printable pdf download

Form 4 Declaration Of Involuntary Admission

Form 4

Declaration of Involuntary Admission

(Section 17 - Involuntary Psychiatric Treatment Act)

I, Dr. ___________________________________________________ (full

name), a psychiatrist on the staff of

_________________________________________ (name of psychiatric

facility), personally examined _____________________________________

(full name of person), at the following dates, times and locations:

Date

Time

Location

(List all examinations done by you since person’s detention. Note: If the person is being detained

under Section 10 of the Act, they must be examined within 72 hours of being detained.)

I have conducted an involuntary psychiatric assessment of this person and it

is my opinion that the person meets all of the following criteria (as set out in

Section 17 of the Act):

the person has a mental disorder

the person is in need of psychiatric treatment in a psychiatric

facility

as a result of the mental disorder, the person (check one or both

boxes)

is threatening or attempting to cause serious harm to himself

or herself or has recently done so, has recently caused

serious harm to himself or herself, is seriously harming or is

threatening serious harm towards another person or has

recently done so

is likely to suffer serious physical impairment or serious

mental deterioration, or both

admission as a voluntary patient

the person requires psychiatric treatment in a psychiatric facility

and is not suitable for inpatient

Form 4 Declaration Of Involuntary Admission