Form HLTH3506 (6) "Medical Report on Examination of Involuntary Patient (Renewal Certificate)" - British Columbia, Canada

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FORM 6
MENTAL HEALTH ACT
[ Section 24, R.S.B.C. 1996, c. 288 ]
MEDICAL REPORT ON EXAMINATION OF INVOLUNTARY PATIENT
(RENEWAL CERTIFICATE)
I,
, M.D., being a physician and the
name of physician (please print)
director of, or a physician authorized by the director of,
name of designated facility
certify that on
I examined
dd / mm / yyyy
first and last name of patient (please print)
who on
was admitted as an involuntary patient to
.
dd / mm / yyyy
name of designated facility
On the basis of my examination, and having taken into consideration the requirements of section 24 (2.1)* of the
Mental Health Act, I have formed the opinion that: (1) sections 22 (3) (a) (ii) and (c)** of the Act continue to describe
the condition of the patient; and (2) that this patient’s status as an involuntary patient should be renewed.
The patient’s status as an involuntary patient is renewed for a period of up to
.
number of month(s)
The patient must be examined again on or before
, the date on which this renewal
dd / mm / yyyy
expires. The reasons that lead me to form the above opinion are:
Note: if above space is insufficient, continue on back of form
signature of physician
dd / mm / yyyy
Notes:
* Section 24 (2.1) requires that the physician’s examination must include:
(a) consideration of all reasonably available evidence concerning the patient’s history of mental disorder including (i) hospitalization for
treatment, and (ii) compliance with treatment plans following hospitalization, and
(b) an assessment of whether there is significant risk that the patient, if discharged, will as a result of mental disorder fail to follow the
treatment plan the director or physician considers necessary to minimize the possibility that the patient will again be detained under
section 22.
** Section 22 (3) of the Act states the following involuntary admission criteria:
The patient is a person with a mental disorder who (i) requires treatment in or through a designated facility, (ii) requires care, supervision and
control in or through a designated facility to prevent the patient’s substantial mental or physical deterioration or for the protection of the patient
or the protection of others, and (iii) cannot suitably be admitted as a voluntary patient.
HLTH 3506 Rev. 2005/06/01
PRINT
CLEAR FORM
FORM 6
MENTAL HEALTH ACT
[ Section 24, R.S.B.C. 1996, c. 288 ]
MEDICAL REPORT ON EXAMINATION OF INVOLUNTARY PATIENT
(RENEWAL CERTIFICATE)
I,
, M.D., being a physician and the
name of physician (please print)
director of, or a physician authorized by the director of,
name of designated facility
certify that on
I examined
dd / mm / yyyy
first and last name of patient (please print)
who on
was admitted as an involuntary patient to
.
dd / mm / yyyy
name of designated facility
On the basis of my examination, and having taken into consideration the requirements of section 24 (2.1)* of the
Mental Health Act, I have formed the opinion that: (1) sections 22 (3) (a) (ii) and (c)** of the Act continue to describe
the condition of the patient; and (2) that this patient’s status as an involuntary patient should be renewed.
The patient’s status as an involuntary patient is renewed for a period of up to
.
number of month(s)
The patient must be examined again on or before
, the date on which this renewal
dd / mm / yyyy
expires. The reasons that lead me to form the above opinion are:
Note: if above space is insufficient, continue on back of form
signature of physician
dd / mm / yyyy
Notes:
* Section 24 (2.1) requires that the physician’s examination must include:
(a) consideration of all reasonably available evidence concerning the patient’s history of mental disorder including (i) hospitalization for
treatment, and (ii) compliance with treatment plans following hospitalization, and
(b) an assessment of whether there is significant risk that the patient, if discharged, will as a result of mental disorder fail to follow the
treatment plan the director or physician considers necessary to minimize the possibility that the patient will again be detained under
section 22.
** Section 22 (3) of the Act states the following involuntary admission criteria:
The patient is a person with a mental disorder who (i) requires treatment in or through a designated facility, (ii) requires care, supervision and
control in or through a designated facility to prevent the patient’s substantial mental or physical deterioration or for the protection of the patient
or the protection of others, and (iii) cannot suitably be admitted as a voluntary patient.
HLTH 3506 Rev. 2005/06/01
PRINT
CLEAR FORM