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: Option 1: Request for Admission (Voluntary Patients) (Fill and Print PDF, 496KB)
• Form 1: Option 2: Request for Admission (Voluntary Patients) (Print PDF, 33KB)

3502

• Form 2: Option 1: Consent for Treatment (Voluntary Patient) (Fill and Print PDF, 492KB)
• Form 2: Option 2: Consent for Treatment (Voluntary Patient) (Print PDF, 37KB)

3503

• Form 3: Option 1: 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)
• Form 3: Option 2: Medical Report (Examination of a Person Under 16 Years of Age, Admitted at the Request of Parent or Guardian) (Renewal Certificate) (Print PDF, 45KB)

3504

• 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: Option 1: Consent for Treatment (Involuntary Patient) (Fill and Print PDF, 496KB)
• Form 5: Option 2: Consent for Treatment (Involuntary Patient) (Print PDF, 40KB)

3506

• Form 6: Option 1: Medical Report on Examination of Involuntary Patient (Renewal Certificate) (Fill and Print PDF, 492KB)
• Form 6: Option 2: Medical Report on Examination of Involuntary Patient (Renewal Certificate) (Print PDF, 50KB)

3507

• Form 7: Option 1: Application for Review Panel Hearing (Fill and Print PDF, 487KB)
• Form 7: Option 2: Application for Review Panel Hearing (Print PDF, 36KB)

3508

• Form 8: Option 1: Review Panel Determination (Fill and Print PDF, 492KB)
• Form 8: Option 2: Review Panel Determination (Print PDF, 39KB)

3509

• Form 9: Option 1: Application for Warrant (Apprehension of Person with Apparent Mental Disorder for Purpose of Examination) (Fill and Print PDF, 504KB)
• Form 9: Option 2: Application for Warrant (Apprehension of Person with Apparent Mental Disorder for Purpose of Examination) (Print PDF, 59KB)

3510

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

3511

• Form 11: Option 1: Request for Second Medical Opinion (Fill and Print PDF, 496KB)
• Form 11: Option 2: Request for Second Medical Opinion (Print PDF, 40KB)

3512

• Form 12: Option 1: Medical Report (Second Medical Opinion) (Fill and Print PDF, 492KB)
• Form 12: Option 2: Medical Report (Second Medical Opinion) (Print PDF, 38KB)

3513

• Form 13: Option 1: Notification to Involuntary Patient of Rights Under the Mental Health Act (Fill and Print PDF, 508KB)
• Form 13: Option 2: Notification to Involuntary Patient of Rights Under the Mental Health Act (Print PDF, 60KB)

3514

• Form 14: Option 1: Notification of Patient Under 16, Admitted by a Parent or Guardian, of Rights Under the Mental Health Act (Fill and Print PDF, 508KB)
• Form 14: Option 2: Notification of Patient Under 16, Admitted by a Parent or Guardian, of Rights Under the Mental Health Act (Print PDF, 58KB)

3515

• Form 15: Option 1: Nomination of Near Relative (Fill and Print PDF, 508KB)
• Form 15: Option 2: Nomination of Near Relative (Print PDF, 47KB)

3516

• Form 16: Option 1: Notification to Near Relative (Admission of Involuntary Patient or Patient Under Age 16) (Fill and Print PDF, 512KB)
• Form 16: Option 2: Notification to Near Relative (Admission of Involuntary Patient or Patient Under Age 16) (Print PDF, 77KB)

3517

• Form 17: Option 1: Notification to Near Relative (Discharge of Involuntary Patient) (Fill and Print PDF, 496KB)
• Form 17: Option 2: Notification to Near Relative (Discharge of Involuntary Patient) (Print PDF, 47KB)

3518

• Form 18: Option 1: Notification to Near Relative (Request for a Review Panel Hearing) (Fill and Print PDF, 496KB)
• Form 18: Option 2: Notification to Near Relative (Request for a Review Panel Hearing) (Print PDF, 48KB)

3518.1

• Form 18.1: Option 1: Notification to Near Relative (Order for a Review Panel Hearing) (Fill and Print PDF, 496KB)
• Form 18.1: Option 2: Notification to Near Relative (Order for a Review Panel Hearing) (Print PDF, 50KB)

3519

• Form 19: Option 1: Certificate of Discharge (Fill and Print PDF, 487KB)
• Form 19: Option 2: Certificate of Discharge (Print PDF, 34KB)

3520

• Form 20: Option 1: Leave Authorization (Fill and Print PDF, 496KB)
• Form 20: Option 2: Leave Authorization (Print PDF, 45KB)

3521

• Form 21: Option 1: Director's Warrant (Apprehension of Patient) (Fill and Print PDF, 492KB)
• Form 21: Option 2: Director's Warrant (Apprehension of Patient) (Print PDF, 42KB)