Form 4 Declaration Of Involuntary Admission Page 2

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as a result of the mental disorder, the person does not have the
capacity to make admission and
treatment decisions
In arriving at my opinion that the person does not have the capacity to make
admission and treatment decisions, I have considered whether the person
fully understands and appreciates all of the following (as set out in Section
18 of the Act):
the nature of the condition for which the specific treatment or
admission is proposed
the nature and purpose of the treatment or admission
the risks and benefits involved in undergoing the specific
treatment or admission proposed
the risks and benefits involved in not undergoing the specific
treatment or admission
AND I have also considered whether the person’s mental
disorder affects the person’s ability to fully appreciate the
consequences of making the treatment decision.
The following information supports my opinion that this person meets the
criteria as checked above:
1)
Observations from my examination of the patient:
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____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
___________________________________________________
2)
Information from other sources:
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

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