Rapid Entry:

Attending physician:

Patient name:

Date of birth:

Residence:

Nearest relative:

Proxy:

Personal Guardian:

Relative/Proxy/Guardian address:

Certificate of Medical Practitioner for Compulsory Admission of a Person to a Mental Health Centre

(Section 24 of The Mental Health Services Act)

Canada, Province of Saskatchewan

Ministry of Health

M-13.1 REG 1

Form G

I, the undersigned a duly qualified medical practitioner with admitting privileges to hereby certify that I, on the day of , , at separately from any other practitioner, personally examined of and after making due inquiry into all the facts in connection with the case of that person necessary to be inquired into in order to enable me to form a satisfactory opinion, I am of the opinion that:

  1. the person is suffering from a mental disorder as a result of which the person is in need of treatment or care and supervision which can be provided only in a mental health centre;
  2. as a result of this disorder, the person is unable to fully understand and to make an informed decision regarding his/her need for treatment or care and supervision; and;
  3. as a result of the mental disorder, the person is likely to cause harm to himself/herself or to others or to suffer substantial mental or physical deterioration if he/she is not detained in a mental health centre;

and I have formed this opinion on the following grounds:

Date (dd/mm/yy)

Signature of examining physician

Date (dd/mm/yy)

Signature of witness

Notification Regarding Appeal Procedures

(Section 33 of The Mental Health Services Act)

Canada
Province of Saskatchewan

Ministry of Health

M-13.1 REG 1

Form M

Notice to:

Name of Patient:

Nearest Relative:

Proxy:

Personal guardian:

Official Representative:

Name of Patient:

is being detained in of the authority of medical certificates dated ; or

has become the subject of a community treatment order dated

Section 34 of The Mental Health Services Act creates rights of appeal by a patient, the patient's nearest relative, any proxy or personal guardian, an official representative or any other person who has a sufficient interest.

A review panel has been appointed to investigate those appeal. A person who intends to submit an appeal is advised to write to the chairperson of the review panel. The name and address of the chairperson of the review panel for this region are as follows:

Name

Address

Date (dd/mm/yy)

Signature of attending physician

Statement by Attending Physician to Review Panel

(Section 22 of The Mental Health Services Act)

Canada
Province of Saskatchewan

Ministry of Health

M-13.1 REG 1

Form O

To the review panel for concerning the appeal by dated the day of , :

his/her detention in on

the order for his/her transfer to

his/her community treatment order

Information concerning the patient:

  1. Full name
  2. Date of birth
  3. Usual place of residence
  4. Name and address of nearest relative, proxy or personal guardian, if any

Attached is a copy/copies of:

the certificate/certificates under which the patient is currently being detained.

the order for transfer (if an order for transfer is under appeal and if a copy of the order is not available, give the reasons for the transfer stated in the order)

the community treatment order

the certificate in support of the community treatment order

portions of the clinical record of the patient which are pertinent to the appeal

Date (dd/mm/yy)

Signature of attending physician / designated person