Form 18 (HLTH3518) "Notification to Near Relative (Request for a Review Panel Hearing)" - British Columbia, Canada

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FORM 18
MENTAL HEALTH ACT
[ Section 34.2, R.S.B.C. 1996, c. 288 ]
NOTIFICATION TO NEAR RELATIVE
(REQUEST FOR A REVIEW PANEL HEARING)
This is to notify
first and last name of near relative (please print)
of
,
address of near relative
being a near relative of
, who is an involuntary patient
first and last name of patient (please print)
in or through
,
name and address of designated facility
phone number
that on
a request was made by the patient or by a person on behalf of the
date (dd / mm / yyyy)
patient for a hearing to determine whether the detention of the patient should continue.
review panel , please contact the
If you wish to participate in the hearing or wish to provide information to the
review panel office for information about the time, date and location of the hearing.
signature of director
date signed (dd / mm / yyyy)
name of director (please print)
How to contact the review panel office:
Mental Health Review Board
302 - 960 Quayside Drive
New Westminster BC V3M 6G2
Tel:
604 660-2325
Fax:
604 660-2403
HLTH 3518 Rev. 2012/05/30
PRINT
CLEAR FORM
FORM 18
MENTAL HEALTH ACT
[ Section 34.2, R.S.B.C. 1996, c. 288 ]
NOTIFICATION TO NEAR RELATIVE
(REQUEST FOR A REVIEW PANEL HEARING)
This is to notify
first and last name of near relative (please print)
of
,
address of near relative
being a near relative of
, who is an involuntary patient
first and last name of patient (please print)
in or through
,
name and address of designated facility
phone number
that on
a request was made by the patient or by a person on behalf of the
date (dd / mm / yyyy)
patient for a hearing to determine whether the detention of the patient should continue.
review panel , please contact the
If you wish to participate in the hearing or wish to provide information to the
review panel office for information about the time, date and location of the hearing.
signature of director
date signed (dd / mm / yyyy)
name of director (please print)
How to contact the review panel office:
Mental Health Review Board
302 - 960 Quayside Drive
New Westminster BC V3M 6G2
Tel:
604 660-2325
Fax:
604 660-2403
HLTH 3518 Rev. 2012/05/30
PRINT
CLEAR FORM