9 Warrant
10 Extension of
warrant
11 Statement of
peace officer
12 Application re
competence
13 Application re
treatment
14 Application re
transfer back to correctional facility
15 Application re
cancellation of certificates
16 Review panel
report
17 Repeal
18 Expiry
Schedule
Interpretation
1(1) In
this Regulation, “Act” means the Mental Health Act.
(2) A
reference in this Regulation to a form is to a form in the Schedule.
Admission certificate
2 An admission certificate under section 2
of the Act must be in Form 1.
Renewal certificate
3 A renewal certificate under section 8 of
the Act must be in Form 2.
Order to return
patient
4 An order under section 20(4) or section
21(1) of the Act to return a formal patient to a facility must be in Form 3.
Transfer into Alberta
5 A certificate under section 24(1) of the
Act authorizing the apprehension and conveyance of a person who comes or is
brought into Alberta to a facility for examination must be in Form 4.
Transfer out of
Alberta
6 A transfer under section 25 of the Act
authorizing the transfer of a formal patient to a jurisdiction outside Alberta
must be in Form 5.
Transfer to another
facility
7 A memorandum of transfer under section
22(1) of the Act authorizing the transfer of a formal patient to another
facility must be in Form 6.
Information
8 An information under section 10 of the
Act must be in Form 7.
Warrant
9 A warrant under section 10 of the Act
directing a peace officer to apprehend and convey a person to a facility for
examination must be in Form 8.
Extension of warrant
10 An order under section 11 of the Act
extending the duration of a warrant must be in Form 9.
Statement of peace
officer
11 The statement under section 12 of the Act
of a peace officer who conveys a person to a facility must be in Form 10.
Application re
competence
12(1) A certificate under section 27(1) of the Act
must be in Part One of Form 11.
(2) A notice of the board under section
27(3) must be in Part Two of Form 11.
(3) A
notice of application under section 27(3) of the Act to have a physician’s
opinion reviewed by a review panel must be in Form 12.
(4) A
notice of hearing under section 40(2) of the Act that the chair of a review panel
must give on receipt of an application under section 27 of the Act must be in
Form 13.
(5) A
report of a decision of a review panel under section 41 of the Act relating to
an application under section 27 of the Act must be in Form 14.
Application re treatment
13(1) An application under section 29(2) of the Act
for an order directing that treatment may be administered to a formal patient
must be in Form 12.
(2) A
notice of hearing under section 40(2) of the Act that the chair of a review
panel must give on receipt of an application under section 29 of the Act must
be in Form 13.
(3) A
report of the decision of a review panel under section 41 of the Act relating
to an application under section 29 of the Act must be in Form 15.
Application re
transfer back to correctional facility
14(1) An application under section 33 of the Act for
an order transferring a person back to a correctional facility must be in Form
12.
(2) A
notice of hearing under section 40(1) of the Act that the chair of a review
panel must give on receipt of an application under section 33 of the Act must
be in Form 13.
(3) A
report of the decision of a review panel under section 41 of the Act relating
to an application under section 33 of the Act must be in Form 16.
Application re cancellation
of certificates
15(1) An application under section 38(1) of the Act
for cancellation of admission certificates or renewal certificates must be in
Form 12.
(2) A
notice of hearing under section 40(1) of the Act that the chair of a review
panel must give on receipt of an application under section 38 of the Act must
be in Form 13.
(3) A
report of a decision of a review panel under section 41 of the Act relating to
an application under section 38(1) of the Act must be in Form 17.
(4) A
report of a decision of a review panel under section 41 of the Act relating to
a deemed application under section 39 of the Act must be in Form 18.
Review panel report
16 As soon as possible after the end of each
year, a review panel must prepare and submit to the Minister a report
summarizing its activities in that year, including the following:
(a) the
number of hearings requested;
(b) the
number of hearings cancelled and the reasons why the hearings were cancelled;
(c) the
number of hearings held before the review panel;
(d) the
number of each type of hearing held before the review panel;
(e) the
place where hearings before the review panel were held;
(f) the
results of each hearing before the review panel;
(g) the
total number of days on which hearings before the review panel were held;
(h) the
number of times a second psychiatric opinion was requested in hearings held
before the review panel.
Repeal
17 The Forms and Review Panels Regulation
(AR 338/89) is repealed.
Expiry
18 For the purpose of ensuring that this
Regulation is reviewed for ongoing relevancy and necessity, with the option
that it may be repassed in its present or an amended form following a review,
this Regulation expires on November 30, 2011.
Schedule
Form 1
Admission Certificate
Mental Health Act
Section 2
I, (print name of physician),
of (address) certify that I
personally examined (print name of person examined) of (home address)
on (date) at (time)
at (place of examination).
In my opinion the person examined is
(i) suffering from mental disorder,
(ii) in a condition presenting or likely to
present a danger to himself/herself or others, and
(iii) unsuitable for admission to a facility other
than as a formal patient.
(Note: All three criteria above must be met.)
I have formed my opinion
(i) on the
following facts observed by me:
(ii) on the following facts communicated
to me by others:
(Note: (i) and (ii) must be completed.)
□ The person is not in a
facility and is to be conveyed for examination to (name of facility) at (address
of facility).
(Place an X in the box
if conveyance is required.)
(date
of
issue)
(time
of
issue)
(signature
of
physician)
(printed
name of
physician)
Form 2
Renewal Certificate
Mental Health Act
Section 8
I, (print name of physician),
of) (address) certify that I
personally examined (print name of person examined) on (date)
at (time) separately from any other
physician.
In my opinion the person examined
is
(i) suffering
from mental disorder,
(ii) in a condition presenting or likely to
present a danger to himself/herself or others, and
(iii) unsuitable to continue at a facility other
than as a formal patient.
(Note: All three criteria above must be met.)
I have formed my opinion
(i) on the
following facts observed by me:
(ii) on the following facts communicated
to me by others:
(Note: (i) and (ii) must be completed.)
The person was examined
at (name of facility).
(date of
issue)
(time of
issue)
(signature
of physician)
(printed
name of physician)
Form 3
Order to Return a Formal Patient to
a Facility
Mental
Health Act
Section 20(4) or 21(1)
To all or any of the
peace officers in Alberta:
(name of formal patient), a formal patient, is
absent without leave pursuant to the Mental
Health Act.
You are hereby ordered to return
the formal patient to (name and address of facility).
Admission certificates (or renewal
certificates) expire on (date) .
Dated this day
of ,
20 .
(signature
of representative of
board
of
facility)
(printed
name of representative)
Form 4
Certificate of Transfer into Alberta
Mental Health Act
Section 24(1)
I have reasonable and probable
grounds to believe that (full name of person) may come or be brought
into Alberta and is
(a) suffering from mental disorder,
(b) in a condition presenting or likely to
present a danger to himself/herself or others, and
(c) unsuitable for admission to a facility other
than as a formal patient.
(Note: All three criteria above must be met.)
Pursuant to section 24(1) of the Mental
Health Act, I authorize a peace officer or (name of person authorized)
to apprehend and convey (full name of person) to a facility for
examination.
(date
of
issue)
(signature
of the Minister of Health
and
Wellness or person designated
by
the Minister of Health and
Wellness)
(printed
name of Minister of Health
and
Wellness or designated person)
Form 5
Transfer of Formal Patient to a
Jurisdiction Outside Alberta
Mental Health Act
Section 25
It appears to me
□ that
(name of formal patient), has come or been brought into Alberta and that
his/her care and treatment is the responsibility of (name of other
jurisdiction).
or
□ that
it would be in the best interests of (name of formal patient) to be
cared for in (name of other jurisdiction).
(Choose one and place an
X in the appropriate box.)
Therefore, I authorize that (name of formal
patient) be transferred to (name of other jurisdiction).
(date
of
issue)
(signature
of the Minister of Health
and
Wellness or person designated
by
the Minister of Health and
Wellness)
(printed
name of Minister of Health
and
Wellness or designated person)
Form 6
Memorandum of Transfer
to Another Facility
Mental Health Act
Section 22(1)
Arrangements have been made with the board of (name
of facility to which the patient is to be transferred) to transfer (name
of formal patient), a formal patient in (name of facility in which
patient is presently detained) to (name of facility to which the patient
is to be transferred).
Dated this
day of ,
20 .
(signature
of representative of
board of sending
facility)
(printed
name of representative)
Form 7
INFORMATION
Mental Health Act
Section 10
This is the information of (name
of informant) of (address of informant) who says that he/she
has reasonable and probable grounds to believe that (name of person) of (address
of person) is
(a) suffering from mental disorder, and
(b) in a condition presenting or likely to present
a danger to himself/herself or others.
SWORN
BEFORE ME at the of )
,
in the Province of Alberta, the )
day of , .)
) (signature of
informant)
(Provincial Judge for the )
Province of Alberta) )
(printed
name of informant)
Form 8
Warrant
Mental Health Act
Section 10
To all or any peace officers in
Alberta:
(name of informant) has brought before me
an information on oath that (name of person) of (address of person)
(a) is suffering from mental disorder, and
(b) is in a condition presenting or likely to
present a danger to himself/herself or others.
I am satisfied that (name of
person) is in a condition presenting or likely to present a danger to
himself/herself or others and that an examination can be arranged in no way
other than by apprehension.
This is to order you to apprehend (name
of person) and convey him/her to a facility for an examination.
Brief reasons:
Dated this
day of ,
20 at
(signature
of Provincial
Judge
for
the Province of
Alberta)
(printed
name of Provincial Judge
for
the Province of
Alberta)
(clerk of the Court)
(date of filing)
Form 9
Extension of Warrant
Mental Health Act
Section 11
To all or any peace
officers in Alberta:
(name of Provincial Judge) issued a warrant dated
to apprehend (name of person).
The warrant has not been executed.
(Name of peace officer), (badge number) of (detachment)
□ has appeared before me to apply for an extension of
the warrant.
or
□ has applied for an extension of the warrant by telephone or
other means of telecommunication, and it appears on the oath of (name of
peace officer) that it is impracticable to appear before me personally and
that there are reasonable grounds for dispensing with an information presented
personally and in writing.
(Choose one and place an
X in the appropriate box.)
This order therefore extends the
duration of the warrant for a period of 7 days from the day on which the
warrant expires.
Dated at
(place) on the
day of ,
20 at (time) .
(signature
of Provincial Judge for
the
Province of
Alberta)
(printed
name of Provincial Judge
for
the Province of Alberta)
(clerk of the Court)
(date of filing)
Form 10
Statement of Peace Officer
on Apprehension
Mental Health Act
Section 12
(name of person apprehended if
known)
was apprehended on (date) at
(time) .
He/She was apprehended at (describe
place and address).
I have reasonable and probable
grounds to believe that
(a) the person apprehended is suffering from
mental disorder,
(b) the person apprehended is in a condition
presenting a danger to himself/herself or others,
(c) the person apprehended should be examined in
the interests of his/her own safety or the safety of others, and
(d) the circumstances are such that to proceed
under section 10 of the Mental Health Act would be dangerous.
(Note: All four criteria above must be met.)
The grounds for my belief are:
Dated this
day of , 20 .
(signature
of peace officer)
(printed
name of peace officer)
(badge
number)
(detachment)
Form 11
Certificate of Incompetence to
Make Treatment Decisions
Mental Health Act
Section 27
Part
One
(To be completed by a physician)
I, (name of physician), am
of the opinion that (name of formal patient) is not mentally competent
to make treatment decisions.
The reasons for my opinion are as
follows:
Dated this day
of ,
20 .
(signature
of physician)
(printed
name of physician)
Part Two
(To be completed by the board of a facility)
To: (name
of formal patient) of (address)
And: (name
of patient’s guardian or agent, if any) of (address)
And: (name
of nearest relative, unless patient objects) of (address)
Take notice that (name of formal
patient) is entitled to have the physician’s opinion about his/her
competence to make treatment decisions reviewed by a review panel by sending to
the chair of the review panel an Application for Review Panel Hearing, in Form
12.
Dated this
day of ,
20 .
(signature
of representative
of
board of
facility)
(printed
name of representative)
Form 12
Application For Review Panel Hearing
Mental Health Act
Sections 27(3), 29(2), 33 and 38(1)
To: (print name of chair of the review
panel)
(address of chair)
I, (printed name of applicant), of (printed
address of applicant) bearing a relationship of (self, relative,
guardian, agent, physician, other) to (name of patient), apply
□ under section 27(3) of the Act for a review of the
attached Certificate of Incompetence to Make Treatment Decisions dated
and signed by .
□ under section 29(2) of the Act for an order directing
that the following treatment (nature of treatment) be administered to (name
of formal patient).
□ under section 33 of the Act for an order transferring (name
of patient) back to (name of correctional facility).
□ under section 38(1) of the Act for cancellation of
admission certificates or renewal certificates issued on (date of issue).
(Choose one and place an
X in the appropriate box.)
Dated this
day of ,
20 .
(signature
of applicant)
Notice
Mental Health Act
I (do) (do not) object to my
nearest relative being informed of the review panel hearings.
(signature
of patient)
(printed
name of patient)
Form 13
Notice of Hearing Before Review Panel
Mental Health Act
Section 40
Application
received
by the review panel
(date)
Take notice that a hearing will be
held
□ under section 27(3) of the Act, for a review of the
physician’s opinion in the attached Certificate of Incompetence to Make
Treatment Decisions relating to (name
of formal patient) dated
and signed by .
□ under section 29(2) of the Act, for an order directing
that the following treatment (nature of
treatment) may be administered to (name
of formal patient) .
□ under section 33 of the Act, for an order transferring (name
of patient) back to a correctional facility.
□ under section 38(1) of the Act, for cancellation of
admission certificates or renewal certificates relating to (name of formal
patient).
□ under section 39 of the Act, for cancellation of renewal
certificates relating to (name of formal patient).
(Choose one and place an
X in the appropriate box.)
The review panel will hear the
application on (date) at (time)
at (place) .
(date
of issue)
(signature
of chair
of review
panel)
(printed name
of chair)
(address)
Form 14
Decision of Review Panel
Regarding Mental Incompetence
to Make Treatment Decisions
Mental Health Act
Sections 27(3) and 41
The formal patient (does) (does
not) object to the nearest relative, (name of nearest relative),
receiving notice of the decision.
The review panel has heard and
considered the application of (name of formal patient) and has decided
□ to cancel the attached Certificate of Incompetence to
Make Treatment Decisions dated
and signed by .
or
□ to refuse to cancel the Certificate
of Incompetence to Make Treatment Decisions dated and
signed by .
(Place an X in the
appropriate box.)
Date of decision:
This decision may be appealed to
the Court of Queen’s Bench within 14 days after receipt of this decision.
(signature of
chair
of review
panel)
(printed name
of chair)
Form 15
Decision of Review Panel
Regarding Treatment
Mental Health Act
Sections 29(2) and 41
The formal patient (does) (does
not) object to the nearest relative, (name of nearest relative),
receiving notice of the decision.
The review panel has heard and
considered the application of (name of board representative or physician)
and has decided
□ to make an order authorizing the following treatment (nature
of treatment) to be administered to (name of formal patient).
□ to refuse to make an order authorizing the following
treatment (nature of treatment) to be administered to (name of formal
patient).
(Place an X in the
appropriate box.)
Date of decision:
This decision may be appealed to
the Court of Queen’s Bench within 14 days after receipt of this decision.
(signature of
chair
of review
panel)
(printed name
of chair)
Form 16
Decision of Review Panel Regarding Transfer
Back to a Correctional Facility
Mental Health Act
Sections 33 and 41
The formal patient (does) (does
not) object to the nearest relative, (name of nearest relative),
receiving notice of the decision.
The review panel has heard and
considered the application of (name of applicant) and has decided
□ to order that (name of patient) be transferred
back to (name of correctional facility).
□ to refuse to make an order.
□ to cancel the admission certificates or renewal
certificates, if any.
□ to refuse to cancel admission certificates or renewal
certificates for the following reasons: .
(Place an X in the
appropriate box(es).)
Date of decision:
This decision may be appealed to
the Court of Queen’s Bench within 14 days after receipt of this decision.
(signature of
chair
of review
panel)
(printed name
of chair)
Form 17
Decision of Review Panel Regarding Admission
Certificates or Renewal Certificates
Mental Health Act
Sections 38(1) and 41
The formal patient (does) (does
not) object to the nearest relative, (name of nearest relative),
receiving notice of the decision.
The review panel has heard and
considered the application of (name of applicant), bearing a
relationship of (self, agent, guardian, other) to (name of formal
patient), and has decided
□ to cancel the admission certificates or renewal
certificates relating to (name of formal patient).
□ to refuse to cancel the admission certificates or renewal
certificates relating to (name of formal patient) for the following
reasons: .
(Place an X in the
appropriate box.)
Date of decision:
This decision may be appealed to
the Court of Queen’s Bench within 14 days after receipt of this decision.
(signature of
chair
of review
panel)
(printed name
of chair)
Form 18
Decision of Review Panel Regarding Renewal
Certificates (Deemed Application)
Mental Health Act
Sections 39 and 41
The formal patient (does) (does
not) object to the nearest relative, (name of nearest relative),
receiving notice of the decision.
The review panel has heard and
considered an application deemed by section 39 of the Act to have been made by (name
of formal patient) and has decided
□ to cancel the renewal certificates relating to (name
of formal patient).
□ to refuse to cancel the renewal certificates relating to (name
of formal patient) for the following reasons:
.
(Place an X in the
appropriate box.)
Date of decision:
This decision may be appealed to
the Court of Queen’s Bench within 14 days after receipt of this decision.
(signature
of chair
of review
panel)
(printed name
of chair)
