Mental Health Forms Regulations

Regulation

Registration: R-049-2018
Source: Unofficial consolidation PDF (justice.gov.nt.ca)
Under: Mental Health Act

This is an unofficial reading copy parsed from the Department of Justice consolidation PDF above — itself an office consolidation, not an official statement of the law. The authoritative text is in the Revised Statutes of the Northwest Territories, 1988 and the annual Statutes volumes.

s.32 amended by Mental Health Act

Contents

1. 1 2. 2 3. 3 4. 4 5. 5 6. 6 7. 7 8. 8 9. 9 10. 10 11. 11 12. 12 13. 13 14. 14 15. 15 16. 16 17. 17 18. 18 19. 19 20. 20 21. 21 22. 22 23. 23 24. 24 25. 25 26. 26 27. 27 28. 28 29. 29 30. 30 31. 31 32. 32

The Commissioner, on the recommendation of the Minister, under section 106 of the Mental Health Act and every enabling power, makes the Mental Health Forms Regulations.

General

(1) The Director of Mental Health appointed under subsection 14(1) of the Mental Health General Regulations may approve forms for the purpose of administering the Act.

(2) Approved forms may include certificates, written information, authorizations, cancellations, designations, statements, treatment plans, notices and amendments.

(1) A certificate issued under the Act must be signed and dated by the person who issues it, and the time that the certificate is signed must be noted on the certificate.

(2) An approved form used for the cancellation of a certificate issued under the Act must be signed and dated by the person who cancels the certificate, and the time that the form is signed must be noted on the form.

(3) Any other approved form, including written information, authorizations, designations, statements, treatment plans, notices and amendments must be signed and dated by the person who makes, issues or provides the form, and the time that the form is signed must be noted on the form.

Notification of Patient Rights and

Other Information

The written form of information that must be provided to a person under subsection 8(1) of the Act and section 2, 3 or 5 of the Mental Health General Regulations must be provided in an approved form and must include the following information:

(a) in respect of the person,

(i) the person’s name,

(ii) the person’s health care number,

(iii) the person’s date of birth,

(iv) the person’s gender, and

(v) the person’s address;

(b) an indication whether the information is being provided to the person or a substitute decision maker, and if applicable, the name of the substitute decision maker;

(d) the name and position of the person providing the form to the detained person or substitute decision maker;

(e) the applicable information required to be provided to the person or substitute decision maker by the Act or the regulations;

(f) the time and date when the form is being provided to the person or substitute decision maker.

Certificate of Involuntary Assessment

A certificate of involuntary assessment, issued under subsection 10(1) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the person subject to the certificate,

(i) the person’s name,

(ii) the person’s health care number,

(iii) the person’s date of birth,

(iv) the person’s gender,

(v) the person’s address, and

(vi) the community where the person resided at the time of the examination by a health professional;

(b) in respect of the health professional who issues the certificate,

(i) the professional’s name, and

(ii) the professional’s health care profession;

(i) the date and time when the health professional personally examined the person subject to the certificate,

(ii) the name and address of the facility where the examination occurred, and

(iii) the facts on which the health professional relied to form the opinion that the person met the involuntary assessment criteria specified in paragraphs 10(1)(a) to (c) of the Act;

(d) the name and address of the designated facility where the person is to be conveyed for involuntary psychiatric assessment;

(e) the date and time of expiration of the authority to apprehend the person subject to the certificate and to convey that person to a designated facility.

Certificate of Involuntary Admission

In addition to the information required under subsection 14(2) of the Act, a certificate of involuntary admission must be made in an approved form and must include the following information in respect of the person subject to the certificate:

(a) the person’s health care number;

(b) the person’s date of birth;

(d) the person’s address;

(e) the community where the person resides or was apprehended under the certificate of involuntary assessment;

(f) the diagnosis or differential diagnosis of the person’s mental condition.

Renewal Certificate

In addition to the information required under subsection 19(2) of the Act, a renewal certificate must be made in an approved form and must include the following information:

(a) in respect of the person subject to the certificate,

(i) the person’s health care number,

(ii) the person’s date of birth,

(iii) the person’s gender,

(iv) the person’s address, and

(v) the diagnosis or differential diagnosis of the person’s mental condition;

(b) an indication whether the renewal certificate is a first, second, third or subsequent renewal certificate;

(c) the name and address of the designated facility where the person named in the certificate is admitted as an involuntary patient.

Cancellation of Certificate of Involuntary

Admission or of Renewal Certificate

A cancellation of a certificate of involuntary admission or renewal certificate, made under paragraph 17(2)(a) or subsections 20(2), 44(2), 46(2) or 50(2) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate being cancelled,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) identification of the certificate being cancelled;

(d) in respect of the psychiatric assessment,

(i) the date and time when the medical practitioner personally examined the patient subject to the certificate being cancelled,

(ii) the name and address of the health facility where the assessment occurred, and

(iii) the facts on which the medical practitioner relied to form the opinion that the involuntary admission criteria are no longer met;

(e) the name and address of the designated facility where the patient named in the certificate being cancelled is admitted as an involuntary patient.

Authorization to Transfer Involuntary Patient to

Facility Within the Northwest Territories

An authorization to transfer an involuntary patient to another designated facility or to another health facility, issued under subsection 23(1) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient being transferred,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(b) the name of the director who issues the authorization;

(d) the name and address of the designated facility or health facility to which the patient is being transferred;

(e) the name, title and contact information for the contact person at the facility to which the patient is being transferred;

(f) a statement by the director issuing the authorization that the director

(i) complied with the requirements of subsection 23(2) of the Act, and

(ii) is satisfied that the transfer is in the best interests of the patient.

Certificate Authorizing Transfer of Involuntary Patient to Facility Outside the Northwest Territories

A certificate authorizing the transfer of an involuntary patient to a psychiatric facility or hospital outside the Northwest Territories, issued under subsection 24(1) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient being transferred,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name of the director who issues the certificate;

(d) the name and address of the psychiatric facility or hospital to which the patient is being transferred;

(e) the name, title and contact information for the contact person at the psychiatric facility or hospital to which the patient is being transferred;

(f) if paragraph 24(1)(a) of the Act applies to the transfer,

(i) information verifying that the patient has come to or been brought into the Northwest Territories from elsewhere and the hospitalization is the responsibility of the jurisdiction to which the patient is to be transferred, and

(ii) evidence of the consent to the transfer by the patient or, if applicable, the patient’s substitute decision maker;

(g) if paragraph 24(1)(b) of the Act applies to the transfer,

(i) a statement by the director issuing the certificate that the director complied with the requirements of subsection 24(3) of the Act and is satisfied that the transfer is in the best interests of the patient, and

(ii) evidence of the consent to the transfer by the patient or, if applicable, the patient’s substitute decision maker;

(h) if paragraph 24(1)(c) of the Act applies to the transfer, a statement by a medical practitioner certifying that the patient cannot be properly cared for, observed, examined, assessed, treated, detained or controlled in a designated facility or health facility in the Northwest Territories.

Authorization to Transfer Patient to Designated

Facility From Health Facility Outside the

Northwest Territories

10.

An authorization to transfer a patient to a designated facility from a health facility outside the Northwest Territories, issued under subsection 25(1) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient being transferred,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name of the director who issues the authorization;

(c) the name and address of the health facility outside the Northwest Territories from which the patient is being transferred;

(d) the name and address of the designated facility to which the patient is being transferred;

(e) the name, title and contact information for the contact person at the health facility outside the Northwest Territories from which the patient is being transferred;

(f) if paragraph 25(1)(a) of the Act applies to the transfer,

(i) a statement by the director issuing the authorization that the director is satisfied that the Northwest Territories is responsible for the patient’s hospitalization, and

(ii) information supporting the director’s statement under subparagraph (i);

(g) if paragraph 25(1)(b) of the Act applies to the transfer,

(i) a statement by the director issuing the authorization that the director is satisfied that the transfer is in the best interests of the patient, and

(ii) information supporting the director’s statement under subparagraph (i).

Treatment Decision Certificate

11.

A treatment decision certificate, issued under subsection 29(3) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s status as a voluntary patient, involuntary patient or other,

(iv) the patient’s date of birth,

(v) the patient’s gender, and

(vi) the patient’s address;

(b) the date of admission of the person as a patient;

(d) the name and address of the attending medical practitioner who issues the certificate;

(e) the date and time of assessment of the mental competence of the patient by the attending medical practitioner;

(f) a statement by the attending medical practitioner issuing the certificate that the practitioner complied with the requirements of subsection 29(2) of the Act and is of the opinion that the patient is not mentally competent to make treatment decisions;

(g) the reasons for the attending medical practitioner’s opinion that the patient is not mentally competent to make treatment decisions.

Cancellation of Treatment Decision Certificate

12.

A cancellation of a treatment decision certificate, made under subsection 29(6) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate being cancelled,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s status as a voluntary patient, involuntary patient or other,

(iv) the patient’s date of birth,

(v) the patient’s gender, and

(vi) the patient’s address;

(b) identification of the certificate being cancelled;

(d) the name and address of the attending medical practitioner who cancels the certificate;

(e) the date and time of assessment of the mental competence of the patient by the attending medical practitioner;

(f) a statement by the attending medical practitioner that the medical practitioner reviewed the mental condition of the patient in accordance with subsection 29(5) of the Act and is of the opinion that the patient has gained mental competence to make treatment decisions;

(g) the reasons for the attending medical practitioner’s opinion that the patient has gained mental competence to make treatment decisions.

Designation of Substitute Decision Maker

13.

(1) A designation of a substitute decision maker, made under subsection 30(2) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient for whom a substitute decision maker is designated,

(i) the patient’s name,

(ii) the patient’s status as a voluntary patient, involuntary patient or other,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate to which the designation relates, including the date and time the certificate was issued and the name of the attending medical practitioner who issued it;

(d) in respect of the person designated as the substitute decision maker,

(i) the person’s name,

(ii) the person’s address,

(iii) the person’s telephone number, and

(iv) the person’s relationship to the patient;

(e) if paragraph 30(4)(d) of the Act applies to the proposed designation, a statement by the substitute decision maker that the substitute decision maker complied with the requirements of paragraph 30(5)(c) of the Act;

(f) the signature of the substitute decision maker and date of signature;

(g) the name and address of the director of the designated facility or the attending medical practitioner, whichever is applicable, who makes the designation of substitute decision maker;

(h) if subsection 30(3) and paragraphs 30(5)(a) and (b) of the Act apply to the proposed designation, a statement by the director of the designated facility or the attending medical practitioner making the designation, whichever is applicable, that he or she has reasonable grounds to believe that the substitute decision maker meets those requirements;

(i) a statement by the director of the designated facility or the attending medical practitioner making the designation, whichever is applicable, as to whether paragraphs 30(4)(a), (b), (c) or

(d) or subsection 30(9) or (10) of the Act applies to the designation of the substitute decision maker, and information about how the paragraph or subsection applies;

(j) a statement that the designation ceases to have effect on the expiration or cancellation of the treatment decision certificate to which the designation relates.

(2) If subsection 30(9) or (10) of the Act applies, the designation must be signed and dated by the patient, and the time that the designation is signed must be noted on the designation.

Short Term Leave Certificate

14.

(1) In addition to the information required under subsection 35(3) of the Act, a short term leave certificate must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate of involuntary admission or renewal certificate to which the patient is subject, including the date and time the certificate was issued, the name of the medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(d) the name and address of the attending medical practitioner who issues the short term leave certificate;

(e) evidence of consent to the issuance of the short term leave certificate by the patient or, if applicable, the patient’s substitute decision maker;

(f) an acknowledgement by the patient that the patient will comply with the applicable conditions during the short term leave;

(g) an acknowledgement by the patient that the patient understands that

(i) the patient remains an involuntary patient during the short term leave,

(ii) the patient may voluntarily return to the designated facility before the expiration of the short term leave certificate,

(iii) the patient is required to return to the designated facility by the date and time of expiration specified in the certificate unless the patient ceases to be an involuntary patient before that time,

(iv) the short term leave certificate may be cancelled if the circumstances specified in subsection 36(1) of the Act apply,

(v) if the short term leave certificate is cancelled, the patient must immediately return to the designated facility on receiving notice of the cancellation, unless the patient ceases to be an involuntary patient before that time, and

(vi) if the patient fails to return as required, the patient may be apprehended by a peace officer and returned to the designated facility.

(2) A short term leave certificate must be signed and dated by the patient or, if applicable, the substitute decision maker, and the time that the certificate is signed must be noted on the certificate.

Cancellation of Short Term Leave Certificate

15.

A cancellation of a short term leave certificate, made under subsection 36(1) of the Act, must be made in an approved form that and must include the following information:

(a) in respect of the patient subject to the certificate being cancelled,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the date of expiration of the certificate of involuntary admission or renewal certificate to which the patient is subject;

(d) identification of the certificate being cancelled, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(e) the name and address of the attending medical practitioner who cancels the certificate;

(f) a statement by the attending medical practitioner identifying whether the certificate is being cancelled under paragraph 36(1)(a) or (b) of the Act and the facts on which the medical practitioner relied to form the opinion that that provision is met;

(g) the name and address of the designated facility to which the patient must return;

(h) contact information to arrange travel back to the designated facility.

Notice of Intention to Issue

Assisted Community Treatment Certificate

16.

Notice of an intention to begin preparations for the issuance of an assisted community treatment certificate, under subsection 37(2) of the Act, must be provided in an approved form and must include the following information:

(a) in respect of the patient,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate of involuntary admission or renewal certificate to which the patient is subject, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(d) the name and address of the attending medical practitioner who is providing the notice;

(e) a statement by the attending medical practitioner providing the notice that the medical practitioner

(i) is of the opinion that the patient meets the criteria specified in paragraphs 37(6)(a) to (d) of the Act, and

(ii) intends to begin preparations for an assisted community treatment certificate for the patient;

(f) the community where the patient would likely reside while subject to the assisted community treatment certificate;

(g) the treatment, services and support that would likely be required for the patient under a community treatment plan;

(h) the name of one or more medical practitioners who could be identified in the community treatment plan for the patient as the medical practitioner responsible for the general supervision and management of the community treatment plan.

Assisted Community Treatment Certificate

17.

(1) In addition to the information required under subsection 38(2) of the Act, an assisted community treatment certificate must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate,

(i) the patient’s health care number,

(ii) the patient’s date of birth,

(iii) the patient’s gender, and

(iv) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate of involuntary admission to which the patient is subject, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(d) an indication whether the assisted community treatment certificate is the original certificate or is a first, second, third or subsequent renewal of that certificate;

(e) if the assisted community treatment certificate is a renewal of the original certificate, identification of each previous assisted community treatment certificate, including the dates the certificates were issued and if applicable, expired, and the names of the medical practitioners who issued the certificates.

(2) An assisted community treatment certificate must be signed and dated by the patient or, if applicable, the substitute decision maker, and the time that the certificate is signed must be noted on the certificate.

Assisted Community Treatment Certificate,

Amendment

18.

An amendment to an assisted community treatment certificate under subsection 6(1) of the Assisted Community Treatment Regulations must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate being amended,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) if applicable, the name and address of the designated facility from which the patient is being transferred;

(c) if applicable, the name and address of the designated facility to which the patient is being transferred and is deemed to be admitted;

(d) identification of the certificate being amended;

(e) the amendment to the certificate.

Community Treatment Plan

19.

(1) In addition to the information required under subsection 40(1) of the Act, a community treatment plan must be prepared in an approved form and must include the following information:

(a) in respect of the patient subject to the community treatment plan,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate of involuntary admission or renewal certificate to which the patient is subject, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(d) the name and address of the attending medical practitioner who prepares the community treatment plan;

(e) in respect of each health professional or other person or body who has agreed to provide supervision, treatment, care or other support under the community treatment plan,

(i) a summary of the health professional’s, person’s or body’s role and obligations under the plan,

(ii) evidence of the consent of the health professional, person or body to the performance of that role and those obligations, and

(iii) evidence of the consent of the health professional, person or body to the disclosure of the person’s or body’s name to the other persons described in paragraphs 40(1)(e) to (h) of the Act;

(f) in respect of each substitute decision maker, family member or other person who has agreed to monitor the patient, assist in the patient’s compliance with the community treatment plan and report to the medical practitioner responsible for general supervision and management of the plan,

(i) evidence of the person’s consent to the performance of that role and those obligations, and

(ii) evidence of the person’s consent to the disclosure of the person’s name to the other persons described in paragraphs 40(1)(e) to (h) of the Act;

(g) an acknowledgement by the patient that the patient understands that

(i) the patient remains an involuntary patient while the assisted community treatment certificate remains in effect,

(ii) the patient may voluntarily return to the designated facility before the expiration of the assisted community treatment certificate,

(iii) the patient is required to return to the designated facility by the date and time specified in the notice of expiration of the assisted community treatment certificate, unless the certificate is renewed or the patient ceases to be an involuntary patient before that time,

(iv) the assisted community treatment certificate may be cancelled if the circumstances specified in subsection 48(1) or 49(2) of the Act apply,

(v) if the assisted community treatment certificate is cancelled, the patient must immediately return to the designated facility on receiving notice of the cancellation, unless the patient ceases to be an involuntary patient before that time, and

(vi) if the patient fails to return as required, the patient may be apprehended by a peace officer and returned to the designated facility;

(h) if the attending medical practitioner who issued the assisted community treatment certificate will not be responsible for the general supervision and management of the community treatment plan, the name, address and signature of the medical practitioner who will be responsible for the plan’s general supervision and management.

(2) A community treatment plan must be signed and dated by the patient or, if applicable, the substitute decision maker, and the time that the plan is signed must be noted on the plan.

Community Treatment Plan, Amendment

20.

(1) An amendment of a community treatment plan made under subsection 7(1) or (2) of the Assisted Community Treatment Regulations must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the community treatment plan,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the person is admitted as a patient;

(c) identification of the certificate of involuntary admission or renewal certificate to which the patient is subject, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(d) identification of the plan being amended and of the related assisted community treatment certificate;

(e) the specifics of the amendment to the plan;

(f) the name and address of the medical practitioner or director who prepares the amendment to the plan;

(g) evidence of consent to the amendment by a health professional or other person or body who has agreed to provide supervision, treatment, care or other support under the plan and who is affected by the amendment;

(h) evidence of consent by a health professional or other person or body who has agreed to provide supervision, treatment, care or other support under the plan to the disclosure of the person’s or body’s name to the other persons described in paragraphs 40(1)(e) to (h) of the Act;

(i) evidence of consent to the amendment by a substitute decision maker, family member or other person who has agreed to monitor the patient, assist in the patient’s compliance with the plan and report to the medical practitioner responsible for general supervision and management of the plan;

(j) if necessary, evidence of the consent by a substitute decision maker, family member or other person who has agreed to monitor the patient, assist in the patient’s compliance with the plan and report to the medical practitioner responsible for general supervision and management of the plan to the disclosure of the person’s name to the other persons described in paragraphs 40(1)(e) to (h) of the Act;

(k) if the medical practitioner or director of the designated facility who prepared the amendment of the plan will not be responsible for the general supervision and management of the plan, the name, address and signature of the medical practitioner who will be responsible for the plan’s general supervision and management.

(2) An amendment to a community treatment plan must be signed and dated by the patient or, if applicable, the substitute decision maker, and the time that the amendment is signed must be noted.

Community Treatment Plan, Report

21.

If a report referred to in paragraph 42(1)(b) of the Act is required by a community treatment plan to be made in written form, the report must be made in an approved form and must include the following information:

(a) the name of the health professional or other person or body who has agreed to provide supervision, treatment, care or other support under the community treatment plan;

(b) the report, as required by the community treatment plan.

Notice Requiring Patient to Return to Designated

Facility on Expiration of Assisted Community

Treatment Certificate

22.

Notice to an involuntary patient who is required to return to a designated facility on the expiration of an assisted community treatment certificate, under subsection 45(1) of the Act, must be provided in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the patient named in the expiring certificate is admitted as an involuntary patient;

(d) identification of the assisted community treatment certificate, including the date and time the certificate was issued, the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(e) the name and address of the designated facility to which the patient must return;

(f) contact information to arrange travel back to the designated facility.

Certificate Requiring Patient to Attend Mandatory

Assessment at Health Facility

23.

A certificate issued under subsection 47(1) of the Act, requiring an involuntary patient who is subject to an assisted community treatment certificate to attend a psychiatric assessment and an assessment under subsection 43(1) of the Act, must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the patient named in the certificate is admitted as an involuntary patient;

(d) identification of the assisted community treatment certificate, including the date and time the certificate was issued and the name of the attending medical practitioner who issued the certificate and the date and time of expiration of the certificate;

(e) the name and address of the medical practitioner or director who issues the certificate requiring the patient to attend the assessment;

(f) a statement by the medical practitioner responsible for the general supervision and management of the patient’s community treatment plan or by the director of the designated facility named in the assisted community treatment certificate

(i) that the medical practitioner or director has reasons to believe that

(A) the patient has failed to comply with one or more of the conditions of the community treatment plan, and

(B) an assessment is required to determine the effectiveness of the community treatment plan and whether the involuntary admission criteria continue to be met, and

(ii) containing the facts on which the medical practitioner or director relied to form the opinion described in subparagraph (i);

(g) evidence showing that reasonable efforts have been made to

(i) assist the patient to comply with the community treatment plan,

(ii) inform the patient of his or her failure to comply with a condition or conditions of the plan, and

(iii) inform the patient of the possible consequences of failure to comply with a condition or conditions of the plan;

(h) a statement by the medical practitioner responsible for the general supervision and management of the patient’s community treatment plan or by the director of the designated facility named in the assisted community treatment certificate that the patient has failed or refused to attend an appointment for a psychiatric assessment or an assessment referred to in subsection 43(1) of the Act;

(i) the name and address of the health facility to which the patient is to be conveyed to for an assessment.

Certificate Cancelling Assisted Community

Treatment Certificate

24.

A certificate issued under subsection 48(1) or 49(2) of the Act cancelling an assisted community treatment certificate must be made in an approved form and must include the following information:

(a) in respect of the patient subject to the certificate being cancelled,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the patient named in the certificate being cancelled is admitted as an involuntary patient;

(d) identification of the assisted community treatment certificate being cancelled, including the date and time the certificate was issued, and the name of the attending medical practitioner who issued it;

(e) the name and address of the medical practitioner or director who issues the certificate of cancellation;

(f) a statement by the medical practitioner or director identifying whether the assisted community treatment certificate is being cancelled under subsection 48(1) or 49(2) of the Act and the facts on which the medical practitioner or director relied to form the opinion that that provision is met;

(g) the name and address of the designated facility to which the patient must return;

(h) contact information to arrange travel back to the designated facility.

Unauthorized Absence Statement

25.

A statement under subsection 53(1) of the Act that a patient is absent from a designated facility without authorization must be issued in an approved form and must include the following information:

(a) in respect of the patient,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) the name and address of the designated facility where the patient is admitted as an involuntary patient;

(d) if applicable, identification of the short term leave certificate or the assisted community treatment certificate to which the patient is or was subject, including the date and time the certificate was issued, the name of the attending medical practitioner who issued it and the date and time of expiration or cancellation of the certificate;

(e) the name and address of the director of a designated facility or medical practitioner who issues the statement;

(f) a statement by the director of the designated facility or attending medical practitioner indicating which of the criteria specified in paragraphs 53(1)(a) to

(c) of the Act have been met and the date and time when the patient was first absent from the designated facility without authority;

(g) the name and address of the designated facility to which the patient is to be conveyed;

(h) a description of the patient;

(i) the last known location of the patient.

Designation of Person to Receive Information

26.

A designation by a patient of a person for the purposes of subparagraph 57(1)(b)(ii) or 58(c)(i) of the Act must be made in an approved form and must

(a) specify the certificates and other documents that are authorized to be provided to the patient’s designate;

(b) specify an expiration date for the authority referred to in paragraph (a); and

Certificate of Mental Incompetence

27.

A certificate of mental incompetence issued under paragraph 79(2)(a) of the Act must be made in an approved form and must include the following information:

(a) in respect of the person named in the certificate,

(i) the person’s name,

(ii) the person’s health care number,

(iii) the person’s date of birth,

(iv) the person’s gender, and

(v) the person’s address;

(b) the date of admission of the person as a patient;

(d) the name and address of the medical practitioner who issues the certificate;

(e) the date and time of assessment of the mental competence of the person by the medical practitioner;

(f) a statement by the medical practitioner that the person is not mentally competent to manage his or her estate;

(g) the reasons for the medical practitioner’s opinion that the person is not mentally competent to manage his or her estate.

Cancellation of Certificate of Mental Incompetence

28.

A cancellation of a certificate of mental incompetence made under subsection 81(1) of the Act must be made in an approved form and must include the following information:

(a) in respect of the patient named in the certificate being cancelled,

(i) the patient’s name,

(ii) the patient’s health care number,

(iii) the patient’s date of birth,

(iv) the patient’s gender, and

(v) the patient’s address;

(b) identification of the certificate being cancelled;

(d) the name and address of the attending medical practitioner who cancels the certificate;

(e) the date and time of assessment of the mental competence of the patient by the medical practitioner;

(f) a statement by the attending medical practitioner that the practitioner examined the patient and is of the opinion that the patient has gained mental competence to manage his or her estate;

(g) the reasons for the attending medical practitioner’s opinion that the patient is mentally competent to manage his or her estate.

Summary Statement Respecting Apprehension or Conveyance

29.

A summary statement made under subsection 3(1) of the Apprehension, Conveyance and Transfer Regulations must be made in an approved form and must include the following information:

(a) in respect of the person,

(i) the person’s name,

(ii) the person’s date of birth,

(iii) the person’s gender,

(iv) the person’s height and weight,

(v) if applicable, any distinguishing features, and

(vi) the person’s address;

(b) if applicable, the name and address of the designated facility or health facility from which the patient is being transferred;

(d) a summary of the certificate, authorization or statement, whichever is applicable, that authorizes the apprehension or conveyance of the person, the name of the director, medical practitioner or health professional who issued it, and the date and time when it was issued and when it will expire;

(e) if known, information in respect of transportation of the person, including scheduled departure date and time;

(f) information respecting any prior incidents, including threats, of harm posed by the person to himself or herself or to any other person;

(g) information respecting any prior incidents, including attempts, of escape from lawful custody by the person;

(h) any other information considered appropriate.

Application to Review Board

30.

An application to the Review Board under subsection 66(1) of the Act must be made in an approved form and must include the following information:

(a) the name of the person or patient;

(b) if the person or patient is not the applicant, the name of the applicant and the applicant’s relationship to the person or patient;

(d) the action or decision being appealed, and the order being requested;

(e) the grounds of the application;

(f) the date of the application;

(g) the signature of the applicant.

Notice to Review Board

31.

A notice provided under section 17 of the Mental Health General Regulations must be made in an approved form and must include the following information:

(a) the name of the patient;

(b) the date of admission of the person as an involuntary patient;

(d) a list of the certificates of involuntary admission and renewal certificates to which the patient has been subject, including the dates when they were issued;

(e) a statement by the director of the designated facility that the triggering of section 68 of the Act is imminent and indicating the date when it will be triggered;

(f) the name of and contact information for the director of the designated facility who provides the notice;

(g) the name of and contact information for the attending medical practitioner;

(h) if applicable, the name of and, if known, the contact information for the patient’s substitute decision maker;

(i) if applicable, the name of and, if known, the contact information for each person designated by the patient under subparagraph 57(1)(b)(ii) or 58(c)(i) of

(j) if applicable, the name of and, if known, the contact information for each health professional or other person or body who has agreed to provide supervision, treatment, care or other support under a community treatment plan;

(k) if applicable, the name of and, if known, the contact information for the patient’s legal counsel.

32.

These regulations come into force on the day on which the Mental Health Act, S.N.W.T. 2015, c.26, comes into force.