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Involuntary Psychiatric Treatment Regulations

made under Section 83 of the

Involuntary Psychiatric Treatment Act

S.N.S. 2005, c. 42

O.I.C. 2007-239 (April 24, 2007, effective July 3, 2007), N.S. Reg. 235/2007


Citation

1     These regulations may be cited as the Involuntary Psychiatric Treatment Regulations.


Definitions for Act and regulations

2     (1)    In these regulations, “Act” means the Involuntary Psychiatric Treatment Act.

 

       (2)    In the Act and its regulations,

 

                (a)    “agent” in Section 72 of the Act means a person appointed by the patient to be the patient’s representative;

 

                (b)    “declaration” does not mean a declaration as defined in the Interpretation Act or the Evidence Act;

 

(c)“month” means 30 days;

 

(d)“witnesses” in subsection 74(1) of the Act does not include a patient.


Designated psychiatric facilities

3     The following hospitals, or parts of hospitals, are designated as psychiatric facilities:

 

                (a)    Queen Elizabeth II Health Sciences Centre;

 

                (b)    Izaak Walton Killam Health Centre;

 

                (c)    Nova Scotia Hospital;

 

                (d)    Aberdeen Hospital of the Pictou County Health Authority;

 

                (e)    Cape Breton Regional Hospital of the Cape Breton District Health Authority;

 

                (f)    Colchester Regional Hospital of the Colchester East Hants Health Authority;

 

                (g)    East Coast Forensic Hospital of the Capital District Health Authority;

 

                (h)    St. Martha’s Regional Hospital of the Guysborough Antigonish-Strait District Health Authority;

 

                (i)     South Shore Regional Hospital of the South Shore District Health Authority;

 

                (j)     Valley Regional Hospital of the Annapolis Valley District Health Authority;

 

                (k)    Yarmouth Regional Hospital of the South West District Health Authority.


Patient rights

4     (1)    When a patient is admitted to a psychiatric facility under the Act, a Declaration of Renewal of Involuntary Admission is issued for a patient or a patient’s status is changed to that of an involuntary patient, the patient and the patient’s substitute decision-maker must be given notice of the following rights orally and in writing in the form approved by the chief executive officer:

 

                (a)    the name and location of the psychiatric facility in or through which the patient is being detained;

 

                (b)    the patient’s right to be discharged if a declaration for renewal of the detention is not issued;

 

                (c)    the patient’s right to retain and instruct counsel;

 

                (d)    the Review Board’s functions and the patient’s right to have their status reviewed by the Review Board or a court;

 

                (e)    the patient’s right to an oral explanation of any document or written communication that affects the patient.

 

       (2)    A psychiatric facility must assist a patient or person who is unable to read or understand a document or written communication that affects them and who wants an oral explanation of the document or written communication.

 

       (3)    A psychiatric facility must post a listing of patients’ rights, as set out in subsection (1), in a place in the psychiatric facility where it can seen by a persons undergoing psychiatric assessments and treatment.


Examination by second psychiatrist

5     If the Review Board arranges for a patient to be examined by a second psychiatrist under subsection 74(2) of the Act, the Review Board must try to engage a psychiatrist who has not been involved with the patient’s case.


Written decisions of Review Board

6     A written decision of the Review Board must include all of the following:

 

                (a)    a summary of the facts of the case;

 

                (b)    the Board’s decision;

 

                (c)    the evidence on which the decision is based.


Review Board’s annual report

7     The Review Board’s annual report must contain all of the following:

 

                (a)    statistics of the Review Board’s activities;

 

                (b)    recommendations to the Minister.


Forms

8     The following forms must be used in accordance with the Act:

 

                (a)    a Detainment of Voluntary Patient form for use under Section 7 of the Act must be in Form 1;

 

                (b)    a Medical Certificate for Involuntary Psychiatric Assessment - Part 1 form for use under Section 9 of the Act must be in Form 2;

 

                (c)    a Medical Certificate for Involuntary Psychiatric Assessment - Part 2 form for use under subsection 10(2) of the Act must be in Form 3;

 

                (d)    a Declaration of Involuntary Admission form for use under Section 17 of the Act must be in Form 4;

 

                (e)    a Declaration of Renewal of Involuntary Admission form for use under Section 21 of the Act must be in Form 5;

 

                (f)    a Declaration of Change of Status form for use under subsection 24(2) of the Act must be in Form 6;

 

                (g)    a Certificate of Leave form for use under Section 43 of the Act must be in Form 7;

 

                (h)    a Certificate of Cancellation of Leave form for use under Section 44 of the Act must be in Form 8;

 

                (i)     a Community Treatment Order form for use under Section 47 of the Act must be in Form 9;

 

                (j)     a Renewal of Community Treatment Order form for use under Section 52 of the Act must be in Form 10;

 

                (k)    a Revocation of Community Treatment Order form for use under Sections 55, 56 and 57 of the Act must be in Form 11;

 

                (l)     a Request for Review form for use under Section 68 of the Act must be in Form 12;

 

                (m)   a Notice of Hearing form for use under Section 70 of the Act must be in Form 13.



Form 1

Detainment of Voluntary Patient

(Section 7 - Involuntary Psychiatric Treatment Act)


I, ___________________________________ (full name), a member of the treatment staff at __________________________________ (name of psychiatric facility), a psychiatric facility, believe on reasonable grounds that ___________________________________ (full name of patient), a voluntary patient at this facility who is requesting discharge meets all of the following criteria:

 

              the patient has a mental disorder

 

              because of the mental disorder, the patient is likely to cause serious harm to himself or herself or to another person or to suffer serious mental or physical deterioration if the patient leaves the psychiatric facility

 

              the patient needs to have a medical examination conducted by a psychiatrist


I am therefore detaining the patient at this psychiatric facility for no more than 3 hours to allow for examination by a psychiatrist.


__________________________

(date of signature)

 

____________________________________

(signature of treatment staff member)

________________ a.m./p.m.

(time of signature)

 

____________________________________

(staff member’s name - printed)



Form 2

Medical Certificate for Involuntary Psychiatric Assessment - Part 1

(Section 9 - Involuntary Psychiatric Treatment Act)


I, Dr. __________________________ (full name), a physician, personally examined _____________________ (full name of person) of __________________________________ (address of person) on ___/___/_____ (dd/mm/yyyy) at ______ a.m./p.m. at _______________ (location of examination).


It is my opinion that the person meets all of the following criteria (as set out in Sections 7 and 8 of the Act):

 

              the person apparently has a mental disorder

 

              the person, as a result of the mental disorder, (check one or both boxes)

 

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused serious harm to himself or herself, is seriously harming or is threatening serious harm towards another person or has recently done so

 

                       the person is likely to suffer serious physical impairment or serious mental deterioration, or both

 

              the person would benefit from psychiatric inpatient treatment in a psychiatric facility and is not suitable for inpatient admission as a voluntary patient


The following information supports my opinion that this person meets the criteria as checked above:

1)    Observations from my examination of the patient:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

2)    Information from other sources:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

Sources of above information (identify specific sources):

____________________________________________________________________________

____________________________________________________________________________

 

I therefore certify that the person named in this certificate be detained, restrained and observed in _______________________ (name of psychiatric facility) for up to 72 hours for an involuntary psychiatric assessment by a psychiatrist.


__________________________

(date of signature)

 

____________________________________

(signature of physician)

________________ a.m./p.m.

(time of signature)

 

____________________________________

(physician’s name - printed)


__________________________________________

Notes:

1)      This certificate must be signed by the physician who examined the person, and, in accordance with Section 9 of the Act, is not effective unless signed within 72 hours after the examination.

2)      A person cannot be taken into custody or detained unless this certificate is accompanied by one of the following:

                    a second Medical Certificate for Involuntary Psychiatric Assessment - Part 1 (Form 2) signed by another physician

                    a Medical Certificate for Involuntary Psychiatric Assessment - Part 2 (Form 3) signed by the same physician who signed Part 1.



Form 3

Medical Certificate for Involuntary Psychiatric Assessment - Part 2

(Subsection 10(2) - Involuntary Psychiatric Treatment Act)


I, Dr. ____________________________ (full name), a physician, signed the attached Medical Certificate for Involuntary Psychiatric Assessment - Part 1 for ___________________________ (full name of person).


I hereby certify that compelling circumstances exist for the involuntary psychiatric assessment of this person and that a second physician is not readily available to examine the person and complete a second Medical Certificate for Involuntary Psychiatric Assessment - Part 1.


__________________________

(date of signature)

 

____________________________________

(signature of physician)

________________ a.m./p.m.

(time of signature)

 

____________________________________

(physician’s name - printed)


__________________________________________

Note:

This form must be accompanied by a Medical Certificate for Involuntary Psychiatric Assessment - Part 1 (Form 2) signed by the same physician.



Form 4

Declaration of Involuntary Admission

(Section 17 - Involuntary Psychiatric Treatment Act)


I, Dr. ___________________________________________________ (full name), a psychiatrist on the staff of _________________________________________ (name of psychiatric facility), personally examined _____________________________________ (full name of person), at the following dates, times and locations:


Date

Time

Location

    

 

 

     

 

 

 

 

 

(List all examinations done by you since person’s detention. Note: If the person is being detained under Section 10 of the Act, they must be examined within 72 hours of being detained.)


I have conducted an involuntary psychiatric assessment of this person and it is my opinion that the person meets all of the following criteria (as set out in Section 17 of the Act):

 

              the person has a mental disorder

              the person is in need of psychiatric treatment in a psychiatric facility

              as a result of the mental disorder, the person (check one or both boxes)

 

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused serious harm to himself or herself, is seriously harming or is threatening serious harm towards another person or has recently done so

 

                       is likely to suffer serious physical impairment or serious mental deterioration, or both

              the person requires psychiatric treatment in a psychiatric facility and is not suitable for inpatient

admission as a voluntary patient

              as a result of the mental disorder, the person does not have the capacity to make admission and

treatment decisions


In arriving at my opinion that the person does not have the capacity to make admission and treatment decisions, I have considered whether the person fully understands and appreciates all of the following (as set out in Section 18 of the Act):

 

              the nature of the condition for which the specific treatment or admission is proposed

 

              the nature and purpose of the treatment or admission

 

              the risks and benefits involved in undergoing the specific treatment or admission proposed

 

              the risks and benefits involved in not undergoing the specific treatment or admission

 

      AND I have also considered whether the person’s mental disorder affects the person’s ability to fully appreciate the consequences of making the treatment decision.


The following information supports my opinion that this person meets the criteria as checked above:

 

1)    Observations from my examination of the patient:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

2)    Information from other sources:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

Sources of above information (identify specific sources):

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

I therefore declare that this person meets the criteria of Section 17 of the Involuntary Psychiatric Treatment Act and is to be admitted to ___________________________ (name of psychiatric facility) as an involuntary patient and is to be detained, observed and examined at the psychiatric facility.


This declaration is effective on the date it is signed and expires on _______________ ___/___/_____ (dd/mm/yyyy - no later than 30 days after date signed).


__________________________

(date of signature)

 

____________________________________

(signature of psychiatrist)

________________ a.m./p.m.

(time of signature)

 

____________________________________

(psychiatrist’s name - printed)


__________________________________________

Note:

In accordance with Section 17 of the Act, this form must be filed with the chief executive officer or designate.



Form 5

Declaration of Renewal of Involuntary Admission

(Section 21 - Involuntary Psychiatric Treatment Act)


I, Dr. ______________________________________ (full name), a psychiatrist on the staff of __________________________ (name of psychiatric facility), am the attending psychiatrist of _____________________________ (full name of patient), an involuntary patient at the facility.


This declaration of renewal renews the Declaration of Involuntary Admission dated ___/___/_____ (dd/mm/yyyy) which expires/expired on ___/___/_____ (dd/mm/yyyy).


This is the ______ (1st, 2nd, 3rd, etc.) renewal of that declaration and expires on ___/___/_____ (dd/mm/yyyy). (See note 2 at end of form.)

The previous renewal of that declaration expires on ___/___/_____ (dd/mm/yyyy).


I personally examined this patient on ___/___/_____ (dd/mm/yyyy) at ______ a.m./p.m. at ____________________ (location of examination).


I have conducted an involuntary psychiatric assessment of this person and it is my opinion that the person meets all of the following criteria (as set out in Section 17 of the Act):

 

              the person has a mental disorder

              the person is in need of psychiatric treatment in a psychiatric facility

              as a result of the mental disorder, the person (check one or both boxes)

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused serious harm to himself or herself, is seriously harming or is

threatening serious harm towards another person or has recently done so

                       is likely to suffer serious physical impairment or serious mental deterioration, or both

              the person requires psychiatric treatment in a psychiatric facility and is not suitable for inpatient

admission as a voluntary patient

              as a result of the mental disorder, the person does not have the capacity to make admission and treatment decisions


In arriving at my opinion that the person does not have the capacity to make admission and treatment decisions, I have considered whether the person fully understands and appreciates all of the following (as set out in Section 18 of the Act):

 

              the nature of the condition for which the specific treatment or admission is proposed

              the nature and purpose of the treatment or admission

              the risks and benefits involved in undergoing the specific treatment or admission proposed

              the risks and benefits involved in not undergoing the specific treatment or admission

 

      AND I have also considered whether the person’s mental disorder affects the person’s ability to fully appreciate the consequences of making the treatment decision.


The following information supports my opinion that this person meets the criteria as checked above:

 

1)    Observations from my examination of the patient:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

2)    Information from other sources:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________

Sources of above information (identify specific sources):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

I therefore declare that the patient meets the requirements of Section 21 of the Involuntary Psychiatric Treatment Act and I renew their status as an involuntary patient, to be detained, observed and examined at the psychiatric facility, effective as of the date this declaration is signed.

__________________________

(date of signature)

 

____________________________________

(signature of attending psychiatrist)

 

 

____________________________________

(attending psychiatrist’s name - printed)

__________________________________________

Notes:

1)      In accordance with Section 21 of the Act, this form must be filed with the chief executive officer or designate.

 

2)      In accordance with Section 22 of the Act, a declaration of renewal may be issued for the following terms:

 

Renewal

Term

1st renewal

up to 1 month

2nd renewal

up to 2 months

3rd and subsequent renewals

up to 3 months

 

3)      If this form is not filled out, the attending psychiatrist must fill out a Declaration of Change of Status (Form 6).

 

 

Form 6

Declaration of Change of Status

(Subsection 24(2) - Involuntary Psychiatric Treatment Act,)

 

I, Dr. ____________________________________ (full name), a psychiatrist, on the staff of __________________________ (name of psychiatric facility), am the attending psychiatrist of _____________________________ (full name of patient), an involuntary patient at the facility.

 

I examined this patient on ___/___/_____ (dd/mm/yyyy) at ______ a.m./p.m. at ____________________ (location of examination).

 

It is my opinion that the patient does not meet one or more of the following criteria (check all that apply):

 

              the patient has a mental disorder

 

              the patient is in need of psychiatric treatment in a psychiatric facility

 

              as a result of the mental disorder, the patient (check one or both boxes)

 

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused serious harm to himself or herself, is seriously harming or is threatening serious harm towards another person or has recently done so

 

                       is likely to suffer serious physical impairment or serious mental deterioration, or both

              the patient requires psychiatric treatment in a psychiatric facility and is not suitable for inpatient admission as a voluntary patient

 

              the patient as a result of the mental disorder, does not have the capacity to make admission and treatment decisions

 

I therefore declare that the patient no longer meets the requirements of Section 17 of the Involuntary Psychiatric Treatment Act and the patient’s status is changed to that of a voluntary patient, effective the date that this declaration is signed.

 

__________________________

(date of signature)

 

____________________________________

(signature of attending psychiatrist)

 

 

____________________________________

(attending psychiatrist’s name - printed)

__________________________________________

Notes:

1)      In accordance with subsection 24(2) of the Act, this form must be filed with the chief executive officer or designate.

2)      In accordance with subsection 24(3) of the Act, when a patient’s status is changed to that of a voluntary patient, the patient must be promptly informed by the attending psychiatrist that they have the right to leave the psychiatric facility, subject to any detention that is lawfully authorized other than under the Involuntary Psychiatric Treatment Act.

 

 

Form 7

Certificate of Leave

(Section 43 - Involuntary Psychiatric Treatment Act,)

 

I, Dr. ________________________________ (full name), a psychiatrist and on the staff of the ___________________________ (name of psychiatric facility), a psychiatric facility, am of the opinion that ______________________________ (full name of patient), an involuntary patient, should be allowed to live outside the psychiatric facility in accordance with this certificate.

 

This certificate allows the patient to live outside the psychiatric facility beginning ___/___/____ (dd/mm/yyyy) and ending on ___/___/_____ (dd/mm/yyyy - date no later than 6 months from beginning date) on the following conditions:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

For this certificate of leave to stay in effect, the patient must comply with the medical treatment that is described in this certificate and must attend appointments with the psychiatrist and any health professionals referred to in this certificate.

 

I confirm that the patient’s substitute decision-maker _____________________________ (full name) has consented to this certificate of leave being issued to the patient.

 

__________________________

(date of signature)

 

____________________________________

(signature of psychiatrist)

________________ a.m./p.m.

(time of signature)

 

____________________________________

(psychiatrist’s name - printed)

__________________________________________

Notes:

1)      In accordance with subsection 43(4) of the Act, a copy of this certificate must be given to all of the following:

              the patient

              the substitute decision-maker who consented to the certificate of leave

              the chief executive officer or designate

              any other health professional involved in the treatment plan

2)      A copy of this certificate should be sent to the Review Board.

3)      This certificate is not effective without the consent of the substitute decision-maker.

4)      In accordance with subsection 44(1) of the Act, the psychiatrist may cancel a certificate of leave without notice for any of the following reasons:

              breach of a condition

              if the psychiatrist is of the opinion that the patient’s condition may present a danger to the patient or others

              the patient fails to report as required by the certificate of leave.

 

 

Form 8

Certificate of Cancellation of Leave

(Section 44 - Involuntary Psychiatric Treatment Act)

 

I, Dr. ________________________________________ (full name), a psychiatrist on the staff of _________________________________ (name of psychiatric facility), am the psychiatrist for ________________________ (full name of patient), an involuntary patient who is currently living outside of the psychiatric facility on a certificate of leave.

 

I am cancelling the patient’s certificate of leave dated ___________________ effective the date of this certificate of cancellation of leave because I have knowledge that (check all that apply)

 

              the patient has breached a condition of their certificate of leave

              the patient’s condition may present a danger to the patient or others

              the patient has failed to report as required by their certificate of leave

 

__________________________

(date of signature)

 

____________________________________

(signature of psychiatrist)

 

 

____________________________________

(psychiatrist’s name - printed)

 

__________________________________________

Note:

This form authorizes a peace officer for up to 30 days after the date it is signed to take the patient into custody and to a psychiatric facility for an involuntary psychiatric assessment.

 

 

Form 9

Community Treatment Order

(Section 47 - Involuntary Psychiatric Treatment Act)

 

I, Dr. _______________________________________ (full name), a psychiatrist on the staff of ___________________________________ (name of psychiatric facility), personally examined ________________________________ (full name of person) within the previous 72 hours on ___/___/_____ (dd/mm/yyyy) at ______ a.m./p.m. at ________________________ (location of examination).

 

It is my opinion that the patient meets all of the following criteria (as set out in clause 47(3)(a) of the Act):

 

              the person has a mental disorder for which the patient is in need of treatment or care and supervision in the community and the treatment and care can be provided in the community

 

              the person, as a result of the mental disorder, (check one or both boxes)

 

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused serious harm to himself or herself, is seriously harming or is threatening serious harm towards another person or has recently done so

 

                       is likely to suffer serious physical impairment or serious mental deterioration, or both

 

              as a result of the mental disorder, the person does not have the full capacity to make treatment decisions

 

              during the immediately preceding 2-year period, the person (check one):

 

                       has been detained in a psychiatric facility for a total of 60 days or longer

 

                       has been detained in a psychiatric facility on 2 or more separate occasions

 

                       has previously been the subject of a community treatment order

              the services that the person requires in order to reside in the community exist in the community, are available to the person, and will be provided to the person

 

In arriving at my opinion that the person does not have the capacity to make admission and treatment decisions, I have considered whether the person fully understands and appreciates all of the following (as set out in Section 18 of the Act):

 

              the nature of the condition for which the specific treatment or admission is proposed

 

              the nature and purpose of the treatment or admission

 

              the risks and benefits involved in undergoing the specific treatment or admission proposed

 

              the risks and benefits involved in not undergoing the specific treatment or admission

 

     AND I have also considered whether the person’s mental disorder affects the person’s ability to fully appreciate the consequences of making the treatment decision.

 

The following information supports my opinion that this person meets the criteria as checked above:

 

1)    Observations from my examination of the patient:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

2)    Information from other sources:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Sources of above information (identify specific sources):

________________________________________________________________________________________________________________________________________________________

 

The following are the services that will be provided to the patient and the community treatment plan that is recommended for the patient:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

The following are the names and contact information of the health professionals who will be providing treatment and support services for the patient:

 

Name

Contact information

 

 

 

 

 

 

 

 

 

 

 

 

 

For this community treatment order to stay in effect, the patient must submit to the medical treatment that is prescribed by their psychiatrist and must attend appointments with the psychiatrist or with the health professionals listed above in the places scheduled from time to time consistent with good medical practice.

 

I confirm that the patient’s substitute decision-maker _____________________________ (full name) has consented to the patient being placed on a community treatment order.

 

This community treatment order begins on ___/___/_____ (dd/mm/yyyy) and expires on ___/___/_____ (dd/mm/yyyy - 6 months after the date that the order is signed) unless it is renewed or terminated at an earlier date.

 

_________________________________

(signature of witness)

 

____________________________________

(signature of psychiatrist)

_________________________________

(witness’s name - printed)

 

____________________________________

(psychiatrist’s name - printed)

__________________________

(date of signature)

 

__________________________

(date of signature)

__________________________________________

Notes:

1)      In accordance with subsection 47(5) of the Act, a copy of this order, together with a notice of the right to hold a hearing before the Review Boards must be given to all of the following:

                    the person

                    the substitute decision-maker who consented to the community treatment order

                    the chief executive officer or designate

                    any other health practitioner or other person who has obligations under the community treatment plan

2)      A copy of this order should be sent to the Review Board.

3)      In accordance with subsection 49(2) of the Act, the psychiatrist who signs this order must notify all of the above listed people of any changes to the patient’s community treatment order.

 

 

Form 10

Renewal of Community Treatment Order

(Section 52 - Involuntary Psychiatric Treatment Act)

 

I, Dr. _______________________________________ (full name), a psychiatrist on the staff of ___________________________________ (name of psychiatric facility), personally examined _____________________________________ (full name of person) who is the subject to [of] a community treatment order on ___/___/_____ (dd/mm/yyyy) at ______ a.m./p.m. at ______________________________ (location of examination).

 

It is my opinion that the person still fulfills the criteria of the original community treatment order dated ___/___/_____ (dd/mm/yyyy) and that the community treatment order has demonstrated efficacy.

 

I therefore renew the community treatment order beginning ___/___/_____ (dd/mm/yyyy) and ending on ___/___/_____ (dd/mm/yyyy - date up to 6 months after date this order is signed), unless it is renewed or ended earlier.

 

_________________________________

(signature of witness)

 

____________________________________

(signature of psychiatrist)

_________________________________

(witness’s name - printed)

 

____________________________________

(psychiatrist’s name - printed)

__________________________

(date of signature)

 

__________________________

(date of signature)

 

__________________________________________

Note:

In accordance with Section 52 of the Act, a community treatment order may be renewed for 6 months at any time before it expires and within 1 month after it expires. There is no limit to the number of times a community treatment order may be renewed.

 

 

 

Form 11A

Revocation of Community Treatment Order

(Section 55 - Involuntary Psychiatric Treatment Act)

 

I, Dr. _____________________________ (full name), am a psychiatrist on the staff of _______________ (name of psychiatric facility).

 

___________________________________ (full name of patient) is an involuntary patient who is the subject of a community treatment order dated ___/___/_____ (dd/mm/yyyy).

 

I am terminating the patient’s community treatment order, effective the date of this order because it is my opinion that the person no longer meets all of the following criteria (as required by subclauses 47(3)(a)(i)-(iii) of the Act) (check all boxes that no longer apply):

 

              the patient has a mental disorder for which they are in need of treatment or care and supervision in the community and the treatment and care of [can] be provided in the community

 

              as a result of the mental disorder, the patient

 

                       is threatening or attempting to cause serious harm to himself or herself or has recently done so, has recently caused harm to himself or herself, is seriously harming or is threatening serious harm towards another person or has recently done so

 

                       is likely to suffer serious physical impairment or serious mental deterioration, or both

 

              as a result of the mental disorder, the patient does not have the full capacity to make treatment decisions

 

_________________________________

(signature of witness)

 

____________________________________

(signature of psychiatrist)

_________________________________

(witness’s name - printed)

 

____________________________________

(psychiatrist’s name - printed)

__________________________

(date of signature)

 

__________________________

(date of signature)

__________________________________________

Notes:

1)      When terminating a community treatment order in accordance with clauses 55(3)(b) and (c) of the Act, a psychiatrist must notify the person that they may live in the community without being subject to the community treatment order and the psychiatrist must notify the following persons that the community treatment order has been terminated:

              the substitute decision-maker who consented to the community treatment order

              the chief executive officer or designate

              any other health practitioner or other person who has obligations under the community treatment plan

2)      A copy of this order should be sent to the Review Board.

 

 

Form 11B

Revocation of Community Treatment Order

(Section 56 - Involuntary Psychiatric Treatment Act)

 

I, Dr. ____________________________________ (full name), am a psychiatrist on the staff of ___________________________________ (name of psychiatric facility).

 

___________________________________ (full name of patient) is an involuntary patient who is the subject of a community treatment order dated ___/___/_____ (dd/mm/yyyy).

 

I am terminating the patient’s community treatment order, effective the date of this order because I have reasonable cause to believe that the person has failed in a substantial or deleterious manner to comply with their obligations under the order based on the following:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________

_________________________________

(signature of witness)

 

____________________________________

(signature of psychiatrist)

_________________________________

(witness’s name - printed)

 

____________________________________

(psychiatrist’s name - printed)

__________________________

(date of signature)

 

__________________________

(date of signature)

__________________________________________

Notes:

1)      When terminating a community treatment order in accordance with subsection 56(1) of the Act, a psychiatrist must request that a peace officer take the person into custody and promptly convey the person to the psychiatrist for a medical examination if all of the following conditions are met:

 

              the psychiatrist has reasonable cause to believe that the person continues to meet the criteria set out in subclauses 47(3)(a)(i), (ii), and (iii) of the Act

              reasonable efforts have been made to do all of the following:

                    locate the person

                    inform the person’s substitute decision-maker of the failure to comply

                    inform the substitute decision-maker of the possibility that the psychiatrist may make a request for the peace officer to take the person into custody and the consequences

                    provide reasonable assistance to the person to comply with the terms of the order.

2)      A request under subsection 56(1) of the Act is sufficient authority, for 30 days after it is issued, for a peace officer to take the person named in it into custody and convey the person to a psychiatrist who shall examine the person to determine whether

              the person should be released without being subject to a community treatment order

              the psychiatrist should issue another community treatment order if the person’s substitute decision-maker consents to the community treatment plan

              the psychiatrist should conduct a psychiatric assessment to determine if the person should be admitted as an involuntary patient under a declaration of involuntary admission.

3)      A copy of this order should be sent to the Review Board

 

 

Form 11C

Revocation of Community Treatment Order

(Section 57 - Involuntary Psychiatric Treatment Act)

 

I, Dr. ____________________________________ (full name), am a psychiatrist on the staff of _________________________________ (name of psychiatric facility).

 

___________________________________ (full name of patient) is an involuntary patient who is the subject of a community treatment order dated ___/___/_____ (dd/mm/yyyy).

 

I am cancelling the patient’s community treatment order, effective the date of this order because the services required for the community treatment order are unavailable.

 

_________________________________

(signature of witness)

 

____________________________________

(signature of psychiatrist)

_________________________________

(witness’s name - printed)

 

____________________________________

(psychiatrist’s name - printed)

__________________________

(date of signature)

 

__________________________

(date of signature)

 

__________________________________________

Notes:

1)      When terminating a community treatment order in accordance with Section 57 of the Act, a psychiatrist must:

                    notify the person of the termination of the order and of the requirement for the psychiatrist to review the person’s condition

                     notify the person’s substitute decision-maker, the chief executive officer and any other health practitioner or other person who has obligations under the community treatment plan.

2)      A copy of this order should be sent to the Review Board.

3)      Within 72 hours of issuing the notice of termination, the psychiatrist must review the person’s condition to determine if the person can continue to live in the community without being subject to an order or if the person or whether a peace officer should be requested to convey the person to a psychiatric facility for an involuntary psychiatric assessment. [sic]

 

 


Form 12

Request for Review

(Section 68 - Involuntary Psychiatric Treatment Act)

 

To: Chair of the Review Board

I ____________________________ (full name of applicant), of ________________________ (address of applicant) apply to the Review Board in the matter of _______________________ (full name of patient), an involuntary patient being treated at or through ___________________ (name of psychiatric facility).

 

I ask the Review Board for a hearing to review (check one)

              a declaration of involuntary admission

              a declaration of renewal of involuntary admission

              a declaration of competency for an involuntary patient under subsection 58(1) of the Hospitals Act

              whether a capable informed consent by a substitute decision-maker has been rendered under subsection 42(1) of the Involuntary Psychiatric Treatment Act

              a community treatment order

              a renewal of a community treatment order

              a certificate of cancellation of leave

 

I am (check one)

 

              the patient for whom the review is requested

              a person authorized by the patient to act on their behalf (authorization is attached)

              the chief executive officer of the psychiatric facility at or through which the patient is being treated

              the Minister of Health and Wellness or ❑ the Minister’s designate

              a member of the Review Board
[Note: the reference to the Minister has been updated in accordance with Order in Council 2011-15 under the Public Service Act, R.S.N.S. 1989, effective January 11, 2011.]

 

__________________________

(date of signature)

 

____________________________________

(signature of applicant)

 

 

____________________________________

(applicant’s name - printed)

 

__________________________________________

Notes:

1)      In accordance with subsection 70(2) of the Act, a notice of this application must be given to all of the following:

                    the applicant

                    the patient

                    the patient’s substitute decision-maker

                    the patient advisor, if no one has been authorized to act on behalf of the patient

                    the patient’s attending psychiatrist

                    the chief executive officer of the psychiatric facility at or through which the patient is being treated

                    every other person who is entitled to be a party

                    any person who, in the opinion of the Review Board, has a substantial interest in the subject-matter of the application.

2)      In accordance with subsection 69(2) of the Act, if a hearing is granted it must begin as soon as reasonably possible after this application and no later than 21 days after this application is received.

 


Form 13

Notice of Hearing

(Section 70 - Involuntary Psychiatric Treatment Act)

 

Take notice that ___________________________________________ (name of applicant) of ________________________________ (address of applicant) has requested that the Review Board review the file of _____________________________________ (full name of patient) of _________________________________________ (address of patient), an involuntary patient being treated at or through ______________________________ (name of psychiatric facility) regarding ____________________________ (decision or order being reviewed).

 

The Review Board will hold a hearing for the review of this file on ___/___/_____ (dd/mm/yyyy) at _______ a.m./p.m. at ____________________________ (location of hearing).

 

The patient, their representative, the other parties and any such individual who, in the opinion of the Review Board, has an interest in the matter may make representations at this hearing.

 

__________________________

(date of signature)

 

____________________________________

(signature of Review Board Chair)

 

 

____________________________________

(Chair’s name - printed)

 

__________________________________________

Notes:

1)      In accordance with Section 72 of the Act, every party is entitled to be represented by counsel or an agent in a hearing before the Review Board.

2)      The Review Board must send a written decision within 10 days of the hearing to all of the following:

                    the person who requested the review

                    the patient

                    the patient’s representative

                    the patient’s substitute decision-maker

                    the patient’s attending psychiatrist

                    the chief executive officer of the psychiatric facility at or through which the patient is being treated

                    the Minister

3)      A written decision of the Review Board may be appealed on any question of law to the Nova Scotia Court of Appeal within 30 days of receiving the decision.