Mental Health and Substance Use Forms

127

• Addictions Information Management System Client Information - SAMPLE ONLY (PDF, 143KB)

3497

• Application for Psychiatric Medication Coverage (fill and print PDF, 562KB)

3573

• Service Utilization Record (fill and print PDF, 240KB)

3574

• Group/Family Counselling Record (fill and print PDF, 321KB)

3579

• Registration and Termination (fill and print PDF, 185KB)

3546

• Appendix B: Checklist - Compliance Self-Assessment for Program Care Standards and Guidelines (fill and print PDF, 390KB)

3547

• Appendix C: Sample Comfort Plan - Provincial Quality, Health & Safety Standards and Guidelines (fill and print PDF, 114KB)

3548

• Appendix D: Sample Personal Safety Plan - Provincial Quality, Health & Safety Standards and Guidelines (fill and print PDF, 86KB)

3549

• Appendix J: Checklist - Targeted Physical Environment and Design Standards (fill and print PDF, 263KB)

3501

• Form 1: Request for Admission (Voluntary Patients) (Fill and Print PDF, 496KB)

3502

• Form 2: Consent for Treatment (Voluntary Patient) (Fill and Print PDF, 492KB)

3503

• Form 3: Medical Report (Examination of a Person Under 16 Years of Age, Admitted at the Request of Parent or Guardian) (Renewal Certificate) (Fill and Print PDF, 492KB)

3504.1

3504.2

• Form 4.1: First Medical Certificate (Involuntary Admission) (Fill and Print PDF, 958KB)
• Form 4.2: Second Medical Certificate (Involuntary Admission) (Fill and Print PDF, 958KB)

3505

• Form 5: Consent for Treatment (Involuntary Patient) (Fill and Print PDF, 496KB)

3506

• Form 6: Medical Report on Examination of Involuntary Patient (Renewal Certificate) (Fill and Print PDF, 492KB)

3507

• Form 7: Application for Review Panel Hearing (Fill and Print PDF, 673KB)

3508

• Form 8: Review Panel Determination (Fill and Print PDF, 492KB)

3509

• Form 9: Application for Warrant (Apprehension of Person with Apparent Mental Disorder for Purpose of Examination) (Fill and Print PDF, 504KB)

3510

• Form 10: Warrant (Apprehension of Person with Apparent Mental Disorder) (Fill and Print PDF, 557KB)

3511

• Form 11: Request for Second Medical Opinion (Fill and Print PDF, 496KB)

3512

• Form 12: Medical Report (Second Medical Opinion) (Fill and Print PDF, 492KB)

3513.1

• Form 13.1: Your Rights Under the Mental Health Act as an Involuntary Patient (Fill and Print PDF, 724KB)

3514.1

• Form 14.1: Your Rights Under the Mental Health Act as a Patient Under Age 16 Admitted on Request of a Parent or Guardian (Fill and Print PDF, 723KB)

3515

• Form 15: Nomination of Near Relative (Fill and Print PDF, 508KB)

3516.1

3516.2

• Form 16.1: Notification to Near Relative of Admission of Involuntary Patient (Fill and Print PDF, 694KB)
• Form 16.2: Notification to Near Relative of Admission of Patient Under Age 16 on Request of a Parent or Guardian (Fill and Print PDF, 683KB)

3517

• Form 17: Notification to Near Relative (Discharge of Involuntary Patient) (Fill and Print PDF, 496KB)

3518

3518.1

• Form 18: Notification to Near Relative (Request for a Review Panel Hearing) (Fill and Print PDF, 496KB)
• Form 18.1: Notification to Near Relative (Order for a Review Panel Hearing) (Fill and Print PDF, 557KB)

3519

• Form 19: Certificate of Discharge (Fill and Print PDF, 487KB)

3520

• Form 20: Leave Authorization (Fill and Print PDF, 496KB)

3521

• Form 21: Director's Warrant (Apprehension of Patient) (Fill and Print PDF, 492KB)

• Form 22: Request for Rights Advice in Facility (Fill and Print PDF, 659KB)