Form 4 Declaration Of Involuntary Admission (Page 3 of 3) in pdf

Form 4 Declaration Of Involuntary Admission Page 3

____________________________________________________________

_____________________________________________________

Sources of above information (identify specific sources):

____________________________________________________________

_______________________________________________________

I therefore declare that this person meets the criteria of Section 17 of the

Involuntary Psychiatric Treatment Act and is to be admitted to

___________________________ (name of psychiatric facility) as an

involuntary patient and is to be detained, observed and examined at the

psychiatric facility.

This declaration is effective on the date it is signed and expires on

_______________ ___/___/_____ (dd/mm/yyyy - no later than 30 days after

date signed).

__________________________

____________________________________

(date of signature)

(signature of psychiatrist)

________________ a.m./p.m.

____________________________________

(time of signature)

(psychiatrist’s name - printed)

__________________________________________

Note:

In accordance with Section 17 of the Act, this form must be filed with the chief executive officer or

designate.

Form 4 Declaration Of Involuntary Admission Page 3