Form 9 (YG3988) "Application to the Capability and Consent Board for Matters Under the Mental Health Act" - Yukon, Canada

ADVERTISEMENT
ADVERTISEMENT

Download Form 9 (YG3988) "Application to the Capability and Consent Board for Matters Under the Mental Health Act" - Yukon, Canada

442 times
Rate (4.6 / 5) 31 votes
FORM 9 – MENTAL HEALTH ACT, SECTION 31
APPLICATION TO THE CAPABILITY AND CONSENT BOARD
FOR MATTERS UNDER THE MENTAL HEALTH ACT
This form is to be completed by the patient, or another person on behalf of the patient, if the patient wishes to appeal
any certificate issued under this act.
Provide a blank copy of this form to the patient when they are given a copy of Form 7 (Certificate of Involuntary Admission),
Form 11 (Certificate of Renewal of Involuntary Admission) or Form 17 (Certificate of Return).
Copies of this form must be provided to the:
Capability and Consent Board (fax 867-633-6954).
IN THE MATTER OF the Mental Health Act
AND IN THE MATTER OF _________________________________________________________ hereinafter called the patient.
NAME OF PERSON
TO:
the chair of the Capability and Consent Board
REGARDING the patient, an involuntary patient of _____________________________________________________,
HEALTH FACILITY
in the province or territory of _____________________________.
I, _____________________________________________________, hereby apply for a review into whether or not the patient:
APPLICANT
(check all that apply)
should be admitted as an involuntary patient;
should be admitted by a renewal of an involuntary admission;
should be transferred to another facility;
should be returned to a hospital after failing to return on a temporary release.
DATED at ______________________________________,
____________________________________________________
Signature of applicant
this ____ day of _________________________, 20 ____.
____________________________________________________
Printed name of applicant
____________________________________________________
Relationship of applicant to patient
YG(3988EQ)F1 Rev.07/2019
Print
Clear
FORM 9 – MENTAL HEALTH ACT, SECTION 31
APPLICATION TO THE CAPABILITY AND CONSENT BOARD
FOR MATTERS UNDER THE MENTAL HEALTH ACT
This form is to be completed by the patient, or another person on behalf of the patient, if the patient wishes to appeal
any certificate issued under this act.
Provide a blank copy of this form to the patient when they are given a copy of Form 7 (Certificate of Involuntary Admission),
Form 11 (Certificate of Renewal of Involuntary Admission) or Form 17 (Certificate of Return).
Copies of this form must be provided to the:
Capability and Consent Board (fax 867-633-6954).
IN THE MATTER OF the Mental Health Act
AND IN THE MATTER OF _________________________________________________________ hereinafter called the patient.
NAME OF PERSON
TO:
the chair of the Capability and Consent Board
REGARDING the patient, an involuntary patient of _____________________________________________________,
HEALTH FACILITY
in the province or territory of _____________________________.
I, _____________________________________________________, hereby apply for a review into whether or not the patient:
APPLICANT
(check all that apply)
should be admitted as an involuntary patient;
should be admitted by a renewal of an involuntary admission;
should be transferred to another facility;
should be returned to a hospital after failing to return on a temporary release.
DATED at ______________________________________,
____________________________________________________
Signature of applicant
this ____ day of _________________________, 20 ____.
____________________________________________________
Printed name of applicant
____________________________________________________
Relationship of applicant to patient
YG(3988EQ)F1 Rev.07/2019
Print
Clear