Forms and Designation Regulation (Alta. Reg. 136/2004)

Alta. Reg. 136/2004

Alberta — Regulations

© Published by Alberta King’s Printer Alberta King’s Printer Suite 700, Park Plaza 10611 - 98 Avenue Edmonton, AB T5K 2P7 Phone: 780-427-4952 E-mail: kings-printer@gov.ab.ca Shop on-line at kings-printer.alberta.ca Province of Alberta Office Consolidation Alberta Regulation 136/2004 With amendments up to and including Alberta Regulation 268/2025 Current as of December 18, 2025 MENTAL HEALTH ACT MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION

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Note All persons making use of this consolidation are reminded that it has no legislative sanction, that amendments have been embodied for convenience of reference only. The official Statutes and Regulations should be consulted for all purposes of interpreting and applying the law.

(Consolidated up to 268/2025) ALBERTA REGULATION 136/2004 Mental Health Act MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION Table of Contents 1

Interpretation 2 Admission certificate 3 Renewal certificate 3.1 Cancellation of admission certif icate or renewal certificate 4 Order to return patient 5 Transfer into Alberta 6 Transfer out of Alberta 7 Transfer to another facility 8 Information 9 Warrant 1 0 Extension of warrant 1 1 Statement of p eace officer 1 2 Application re competence 1 3 Application re treatment 1 4 Application re transfer back to correctional facility 1 5 Application for cancellation and orders to issue community treatment orders 15.1 Community treatment order forms 15.2 Designation of facilities 15.3 Transitional 1 7 Repeal 1 8 E x p i r y

Schedule

Interpretation 1(1) In this Regulation, (a) “Act” means the Mental Health Act; (b) “appropriate provincial health agency” means the provincial health agency established for the mental health

Section 2 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 2 and addiction health services sector under the Provincial Health Agencies Act; (c) “issuing qualified health professional” means the qualifie d health professional who last issued, renewed or amended a community treatment order; (d) “provincial health agency” means a provincial health agency under the Provincial Health Agencies Act; (d.1) “provincial health corpora tion” means a provincial health corporation under the Provincial Health Agencies Act; (e) “regional health author ity” means a regional health authority under the Provincial Health Agencies Act.

(2) A reference in this Regulation to a form is to a form in the Schedule. AR 136/2004 s1;342/2009;183/2020;126/2024;199/2025 Admission certificate 2 An admission certificate under

section 2 of the Act must be in Form 1. Renewal certificate 3 A renewal certificate under

section 8 of the Act must be in Form 2. Cancellation of admission certificate or renewal certificate 3.1 A cancellation of an admission certificate or renewal certificate under

section 31 of the Act must be in Form 2.1. AR 183/2020 s4 Order to return patient 4 An order under

section 20(4) or

section 21(1) of the Act to return a formal patient to a facility must be in Form 3. Transfer into Alberta 5 A certificate under

section 24(1) of the Act authorizing the apprehension and conveyance of a person who comes or is brought into Alberta to a facility for examination must be in Form 4. Transfer out of Alberta 6 A transfer under

section 25 of the Act authorizing the transfer of a formal patient to a jurisdiction outside Alberta must be in Form

Section 7 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 3 Transfer to another facility 7 A memorandum of transfer under

section 22(1) of the Act authorizing the transfer of a formal patient to another facility must be in Form 6. Information 8 An information under

section 10 of the Act must be in Form 7. Warrant 9 A warrant under

section 10 of the Act directing a peace officer to apprehend and convey a person to a facility or secure location for examination must be in Form 8. AR 136/2004 s9;183/2020 Extension of warrant 10 An order under

section 11 of the Act extending the duration of a warrant must be in Form 9. Statement of peace officer 11 The statement under

section 12 of the Act of a peace officer who conveys a person to a facility or secure location must be in Form 10. AR 136/2004 s11;183/2020 Application re competence 12(1) A certificate under

section 27(1) of the Act must be in

Part I of Form 11.

(2) A notice of the board under

section 27(3) must be in

Part II of Form 11.

(3) A notice of application under

section 27(3) of the Act to have a physician’s opinion reviewed by a review panel must be in Form 12.

(4) A notice of hearing under

section 40(2) of the Act that the chair of a review panel must give on receipt of an application under

section 27 of the Act must be in Form 13.

(5) A report of a decision of a review panel under

section 41 of the Act relating to an application under

section 27 of the Act must be in Form 14. AR 136/2004 s12;183/2020

Section 13 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 4 Application re treatment 13(1) An application under

section 29(2) of the Act for an order directing that treatment may be administered to a formal patient must be in Form 12.

(2) A notice of hearing under

section 40(2) of the Act that the chair of a review panel must give on receipt of an application under

section 29 of the Act must be in Form 13.

(3) A report of the decision of a review panel under

section 41 of the Act relating to an application under

section 29 of the Act must be in Form 15. Application re transfer back to correctional facility 14(1) An application under

section 33 of the Act for an order transferring a person back to a correctional facility must be in Form 12.

(2) A notice of hearing under

section 40(1) of the Act that the chair of a review panel must give on receipt of an application under

section 33 of the Act must be in Form 13.

(3) A report of the decision of a review panel under

section 41 of the Act relating to an application under

section 33 of the Act must be in Form 16. Application for cancellation and orders to issue community treatment orders 15(1) An application under

section 38 of the Act for (

a) the cancellation of an ad mission certificate, renewal certificate or community treatment order, or (

b) an order to issue a community treatment order must be in Form 12.

(2) A notice of hearing under

section 40(1) of the Act that the chair of a review panel must give on receipt of an application under

section 38 of the Act or with respect to a deemed application under

section 39 of the Act must be in Form 13.

(3) A report of a decision of a review panel under

section 41 of the Act relating to an application under

section 38 of the Act (

a) relating to an applicatio n for the cancellation of an admission certificate or a renewal certificate must be in Form 17, and

Section 15.1 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 5 (

b) relating to an application for an order to issue a community treatment order must be in Form 17.1.

(4) A report of a decision of a review panel under

section 41 of the Act relating to a deemed application under

section 39 of the Act must be in Form 18. AR 136/2009 s15;342/2009;183/2020 Community treatment order forms 15.1(1) A community treatment order must be issued in Form 19.

(2) A community treatment order must be renewed in Form 20.

(3) An amendment to the treatment or care plan set out in the community treatment order must be in Form 21.

(4) Notice of the cancellation or expiry of a community treatment order must be in Form 22.

(5) An order for the apprehension of a person who is subject to a community treatment order under

section 9.6 of the Act must be in Form 23.

(6) An examination of a person who is subject to a community treatment order and who has been apprehended under

section 9.6 of the Act must be recorded in Form 24.

(7) Repealed AR 183/2020 s8.

(8) A written statement in respect of the issuance, renewal or amendment of a community treatment order for the purposes of

section 14(1.1)(

a) of the Act must be in Form 19, Form 20 or Form 21, as applicable.

(9) A report by a treatment or care provider that a person who is subject to a community treatment order has failed to comply with the treatment and care plan in the community treatment order must be in Form 25. AR 342/2009 s4;183/2020;115/2021;239/2021 Designation of facilities 15.2(1) Subject to subsection (5), the following places are designated as facilities for the purposes of

section 1(1)(

d) of the Act: (

a) Alberta Hospital Edmonton; (

b) Centennial Centre for Men tal Health and Brain Injury; (

c) Peter Lougheed Centre;

Section 15.2 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 6 (

d) Foothills Medical Centre; (

e) Misericordia Community Hospital; (

f) Royal Alexandra Hospital; (

g) University of Alberta Hospital; (

h) Grey Nuns Community Hospital; (

i) Chinook Regional Hospital; (

j) Medicine Hat Regional Hospital; (

k) Northern Lights Regional Health Centre; (

l) repealed AR 239/2021 s3; (

m) Rockyview General Hospital; (

n) Claresholm Centre for M ental Health and Addictions; (

o) Red Deer Regional Hospital Centre; (

p) Southern Alberta Fore nsic Psychiatry Centre; (

q) St. Therese - St. Paul Healthcare Centre; (

r) Villa Caritas; (

s) South Health Campus; (

t) Alberta Children’s Hospital; (

u) Stollery Children’s Hospital; (

v) Grande Prairie Regional Hospital.

(2) Subject to subsection (5), the following places are designated as facilities for the purposes of

section 1(1)(

d) of the Act, only for the purposes of

section 13 of the Act: (

a) Helen Hunley Forensic Pavilion at Alberta Hospital Edmonton; (

b) Southern Alberta Fore nsic Psychiatry Centre.

(3) Subject to subsection (5), the following places are designated as facilities for the purposes of

section 1(1)(

d) of the Act, except for the purposes of sections 4(1)(a), 9.6, 10, 12 and 24 of the Act: (

a) Glenrose Rehabilitation Hospital;

Section 15.3 AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 7 (

b) repealed AR 115/2021 s3.

(4) Subject to subsection (5), the following places are designated as facilities for the purposes of

section 1(1)(

d) of the Act, only for the purposes of

section 9.6 of the Act: (

a) Edmonton Community Health Hub North; (

b) Sheldon M. Chumir Health Centre.

(5) If a place listed in subsections (1) to (4) is an approved hospital, only the mental health and addiction health services sector in the approved hospital is designated as a facility. AR 183/2020 s9;115/2021;239/2021;191/2022;199/2025 Transitional 15.3(1) In this section, (a) “previous forms” means the forms as they existed immediately before the coming into force of this section; (b) “transitional period” mean s the period ending 6 months after the coming into force of this section.

(2) The previous forms may continue to be used for the purposes of this Regulation during the transitional period. AR 268/2025 s2 16 Repealed AR 14/2009 s4. Repeal 17 The Forms and Review Panels Regulation (AR 338/89) is repealed. Expiry 18 For the purpose of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on November 30, 2030. AR 136/2004 s18;190/2011;147/2017;183/2020;268/2025

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 8

Schedule Form 1 Admission Certificate Mental Health Act

Section 2 I, (name of physician or other qualified health professional) of (business address) , am □ a physician. o r □ a qualified health professional other than a physician. I certify that I examined (name of person examined) of (home address) on (date) at (time) using the following means: □ in person at (place of examination) □ via video conference at (location of person who was examined) In my opinion the person examined (

a) is suffering from mental disorder, based on the following facts □ observed by me, and/or □ communicated to me by others: (

b) has the potential to benefit from treatment for the mental disorder, based on the following facts □ observed by me, and/or □ communicated to me by others: (

c) is, within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, based on the following facts □ observed by me, and/or

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 9 □ communicated to me by others: a n d (

d) is unsuitable for admission to a facility other than as a formal patient, based on the following facts □ observed by me, and/or □ communicated to me by others: (Note: All 4 criteria above must be met.) □ The person is not in a facility and is to be conveyed for examination to (name of facility) at (address of facility). (Place an X in the box if conveyance is required.) (date of issue) (time of issue) (signature of physician or other qualified health professional) (printed name of physician or other qualified health professional) Form 2 Renewal Certificate Mental Health Act

Section 8 I, (name of psychiatrist or other qualified health professional) of (business address) , am □ a psychiatrist. o r □ a qualified health professional other than a psychiatrist. I certify that I examined (name of person examined) on (date) at (time) separately from any other qualified health professional.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 10 In my opinion the person examined (

a) is suffering from mental disorder, based on the following facts □ observed by me, and/or □ communicated to me by others: (

b) has the potential to benefit from treatment for the mental disorder, based on the following facts □ observed by me, and/or □ communicated to me by others: (

c) is, within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, based on the following facts □ observed by me, and/or □ communicated to me by others: a n d (

d) is unsuitable for admission to a facility other than as a formal patient, based on the following facts □ observed by me, and/or □ communicated to me by others: (Note: All 4 criteria above must be met.) The person was examined at (name of facility) (date of issue) (time of issue) (signature of psychiatrist or other qualified health professional) (printed name of psychiatrist or other qualified health professional)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 11 Form 2.1 Cancellation of Admission Certificates or Renewal Certificates Mental Health Act

Section 31(4) I, (name of physician) of (business address) , certify that I examined (name of person examined) on (date) at (time) at (place of examination) . In my opinion, the person examined no longer meets one or more of the following criteria under which the person became the subject of 2 admission certificates or 2 renewal certificates: (

a) is suffering from mental disorder; (

b) has the potential to benefit from treatment for the mental disorder; (

c) is, within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder; (

d) is unsuitable for admission to a facility other than as a formal patient. I have formed my opinion (

a) on the following facts observed by me (required): (

b) on the following facts communicated to me by others: □ I have informed the patient tha t they are no longer a formal patient under the Mental Health Act. Dated this day of , 20 (signature of physician) (printed name of physician)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 12 Form 3 Order to Return a Formal Patient to a Facility Mental Health Act

Section 20(4) or 21(1) To all or any peace officers in Alberta: (name of formal patient), a formal patient, is absent without leave pursuant to the Mental Health Act. You are hereby ordered to return the formal patient to (name and address of facility). Admission certificates (or renewal certificates) expire on (date) . Dated this day of , 20 . (signature of representative of board of facility) (printed name of representative) If the person is returned to the facility after the expiry of the admission certificates or renewal certificates to which they are subject, under

section 21(3) of the Act, the person is deemed to be a person in respect of whom one admission certificate has been issued. Form 4 Certificate of Transfer into Alberta Mental Health Act

Section 24(1) I have reasonable and probable grounds to believe that (full name of person) may come or be brought into Alberta and (

a) is suffering from mental disorder,

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 13 (

b) is, within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, and (

c) is unsuitable for admission to a facility other than as a formal patient. (Note: All 3 criteria above must be met.) Pursuant to

section 24(1) of the Mental Health Act, I authorize a peace officer or (name of person authorized) to apprehend and convey (full name of person) to a facility as defined in the Mental Health Act. (date of issue) (signature of the Minister of Mental Health and Addiction or person designated by the Minister of Men tal Health and Addiction) (printed name of Minister of Mental Health and Addiction or designated person) Form 5 Transfer of Formal Patient to a Jurisdiction Outside Alberta Mental Health Act

Section 25 It appears to me □ that (name of formal patient) has come or been brought into Alberta and that their care and treatment is the responsibility of (name of other jurisdiction). or □ that it would be in the best interests of (name of formal patient) to be cared for in (name of other jurisdiction). (Choose one and place an X in the appropriate box.)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 14 Therefore, I authorize that (name of formal patient) be transferred to (name of other jurisdiction). (date of issue) (signature of the Minister of Mental Health and Addiction or person designated by the Minister of Mental Health and Addiction) (printed name of Minister of Mental Health and Addiction Health or designated person) Form 6 Memorandum of Transfer to Another Facility Mental Health Act

Section 22(1) (Note: This form needs to be completed only when a patient is transferred from (

a) a designated facility operated by a provincial health agency or regional health authority to the Grey Nuns Community Hospital, Misericordia Community Hospital or Villa Caritas, or (

b) the Grey Nuns Community Hospital, Misericordia Community Hospital or Villa Caritas to a designated facility operated by a provincial health agency or regional health authority.) Arrangements have been made with the board of (name of facility to which the patient is to be transferred) to transfer (name of formal patient), a formal patient in (name of facility in which patient is presently detained), to (name of facility to which the patient is to be transferred). Dated this day of , 20 . (signature of representative of board of sending facility) (printed name of representative)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 15 Form 7 Information Mental Health Act

Section 10 This is the information of (name of informant) of (address of informant) who says that they have reasonable and probable grounds to believe that (name of person) of (address of person) is □ suffering from mental disorder, and within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, or □ is subject to a community treatment order and is not complying with the order.

SWORN BEFORE ME at the of ) , in the Province of Alberta, the ) day of , 20 .) ) (signature of informant) (Justice of the Alberta ) Court of Justice) ) (printed name of informant) Form 8 Warrant Mental Health Act

Section 10 To all or any peace officers in Alberta: (name of informant) has brought before me an information on oath that (name of person) of (address of person) □ is suffering from mental disorder, and within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, or □ is subject to a community treatment order and is not complying with the order.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 16 I am satisfied that (name of person) □ is within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, or □ is subject to a community treatment order and is not complying with the order, and that an examination can be arranged in no way other than by apprehension. This warrant is to order you to apprehend and convey (name of person) to a facility or secure location for an examination.

Brief reasons: Dated this day of , 20 at . (signature of Justice of the Alberta Court of Justice ) (printed name of Justice of the Alberta Court of Justice ) (clerk of the Court) (date of filing) Form 9 Extension of Warrant Mental Health Act

Section 11 To all or any peace officers in Alberta: (name of Justice of the Alberta Court of Justice) issued a warrant dated to apprehend (name of person). The warrant has not been executed. (name of peace officer), (Reg./ID number) of (agency), (detachment/district office), □ has appeared before me to apply for an extension of the warrant. or

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 17 □ has applied for an extension of the warrant by telephone or other means of telecommunication, and it appears on the oath of (name of peace officer) that it is impracticable to appear before me personally and that there are reasonable grounds for dispensing with an information presented personally and in writing. (Choose one and place an X in the appropriate box.) This order therefore extends the duration of the warrant for a period of 7 days from the day on which the warrant expires.

Dated at (place) on the day of , 20 at (time) . (signature of Justice of the Alberta Court of Justice ) (printed name of Justice of the Alberta Court of Justice ) (clerk of the Court) (date of filing) Form 10 Statement of Peace Officer on Apprehension Mental Health Act

Section 12 (name of person apprehended, if known) was apprehended on (date) at (time) . This person was apprehended at (describe place and address). I have reasonable and probable grounds to believe that □ the person apprehended is suffering from a mental disorder*, based on the following: (Note: An X must be placed in the first box above and grounds provided in the space provided.)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 18 *The Mental Health Act defines a mental disorder as a substantial disorder of thought, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognize reality, or ability to meet the ordinary demands of life, but does not include a disorder in which the resulting impairment is persistent and is caused solely by an acquired or congenital irreversible brain injury. AND □ all of the following apply: (

a) the person apprehended is, within a reasonable time, likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment as a result of or related to the mental disorder; (

b) the person apprehended should be examined in the interests of their own safety or the safety of others; (

c) the circumstances are such that to proceed under

section 10 of the Mental Health Act would be dangerous, based on the following: OR □ all of the following apply: (

a) the person apprehended is subject to a community treatment order and is not complying with the order; (

b) the person apprehended should be examined in the interests of their own safety or the safety of others; (

c) the circumstances are such that to proceed under

section 10 of the Mental Health Act would be dangerous, based on the following: (Note: An X must be placed in the second or third box above and grounds provided in the related space provided.) Dated this day of , 20 .

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 19 (signature of peace officer) (printed name of peace officer) (phone number, including extension number, if any) (agency file number) (Reg./ID number) (agency), (detachment/district office) Form 11 Certificate of Incompetence to Make Treatment Decisions Mental Health Act

Section 27

PART I (To be completed by a physician) I, (name of physician), am of the opinion that (name of formal patient) is not mentally competent to make treatment decisions. In my opinion the formal patient (

a) is not able to understand the subject matter relating to t he decisions, based on the following facts □ observed by me, and/or □ communicated to me by others: and/or (

b) is not able to appreciate th e consequences of making the decisions, based on the following facts □ observed by me, and/or □ communicated to me by others: Dated this day of , 20 .

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 20 (signature of physician) (printed name of physician)

PART II (To be completed by the board of a facility) To: (name of formal patient) of (address) And: (name of patient’s agent, if any) of (address) And: (name of patient’s guardian, if any) of (address) And: (name of nearest relative) of (address) , unles s the patient objects on reasonable grounds: Take notice that (name of formal patient) is entitled to have the physician’s opinion about their competence to make treatment decisions reviewed by a review panel by sending to the chair of the review panel an Application for Review Panel Hearing, in Form 12.

Dated this day of , 20 . (signature of representative of board of facility) (printed name of representative of board of facility ) Form 12 Application for Review Panel Hearing Mental Health Act Sections 27(3), 29(2), 33 and 38(1) and

(1.1) To: (name of chair of the review panel) (business address of chair) I, (name of applicant) of (address of applicant), bearing a relationship of (self, agent, guardian, physician, other (specify)) to (name of patient or person who is subject to a community treatment order), apply □ under

section 27(3) of the Act for a review of the attached Certificate of Incompetence to Make Treatment Decisions, dated and signed by .

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 21 □ under

section 29(2) of the Act for an order directing that the following treatment (nature of treatment) be administered to (name of formal patient). □ under

section 33 of the Act for an order transferring (name of patient) back to (name of correctional facility). □ under

section 38(1) of the Act for cancellation of admission certificates or renewal certificates issued on (date of issue). □ under

section 38(1) of the Act for the board to issue a community treatment order. □ under

section 38(1.1) of the Act for cancellation of the community treatment order (issued/amended/renewed) on (date of issue/amendment/renewal). (Choose all that apply and place an X in the appropriate box(es).) Choice of review panel hearing method: □ I consent to this review pan el hearing being conducted by video conference. □ I consent to this review pan el hearing being conducted in person. □ I consent to this review pan el hearing being conducted by telephone. (Choose all that apply and place an X in the appropriate box(es).) Legal Aid: □ I wish for Legal Aid Alberta to provide free legal representation at the hearing.

Contact information: □ For the purposes of ensuring duty counsel and the panel can contact me, I understand that I need to confirm and update my contact information, as necessary, before and after the hearing. My preferred contact phone number is . Dated this day of , 20 . (signature of applicant)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 22 Notice to the Nearest Relative: I □ (do) □ (do not) object to my nearest relative, (name of nearest relative) of (address of nearest relative), being informed of the review panel hearings. (signature of patient or person who is subject to the community treatment order) (printed name of patient or person who is subject to the community treatment order) Form 13 Notice of Hearing Before Review Panel Mental Health Act

Section 40 Application received by the review panel (date) Take notice that a hearing will be held (Choose all that apply and place an X in the appropriate box(es).) □ under

section 27(3) of the Act for a review of the physician’s opinion in the attached Certificate of Incompetence to Make Treatment Decisions relating to (name of formal patient) dated and signed by . □ under

section 29(2) of the Act for an order directing that the following treatment (nature of treatment) may be administered to (name of formal patient) . □ under

section 33 of the Act for an order transferring (name of patient) back to a correctional facility. □ under

section 38(1) of the Act for cancellation of admission certificates or renewal certificates relating to (name of formal patient). □ under

section 38(1) of the Act for the board to issue a community treatment order relating to (name of formal patient).

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 23 □ under

section 38(1.1) of the Act for cancellation of the community treatment order (issued/amended/renewed) on (date of issue/amendment/renewal) relating to (name of person who is subject to the community treatment order). □ under

section 39 of the Act for (Choose one and place an X in the appropriate box.) □ cancellation of renewal c ertificates relating to (name of formal patient). or □ cancellation of the community treatment order relating to (name of person who is subject to the community treatment order). The review panel will hear the application on (date) at (time) at (place) .

Review panel hearing method: □ The review panel hearing will be conducted by video conference. □ The review panel hearing will be conducted in person. □ The review panel hearing will be conducted by telephone. (date of issue) (signature of chair of review panel) (printed name of chair) (contact information) Form 14 Decision of Review Panel Regarding Mental Incompetence to Make Treatment Decisions Mental Health Act Sections 27(3) and 41 The formal patient (does) (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 24 The review panel has heard and considered the application of (name of formal patient) and has decided □ to cancel the attached Certif icate of Incompetence to Make Treatment Decisions dated and signed by . □ to refuse to cancel the a ttached Certificate of Incompetence to Make Treatment Decisions dated and signed by . (Place an X in the appropriate box.) Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision. (signature of chair of review panel) (printed name of chair) Form 15 Decision of Review Panel Regarding Treatment Mental Health Act Sections 29(2) and 41 The formal patient (does) (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision.

The review panel has heard and considered the application of (name of board representative or physician) and has decided □ to make an order authorizing the following treatment (nature of treatment) to be administered to (name of formal patient). □ to refuse to make an order authorizing the following treatment (nature of treatment) to be administered to (name of formal patient). (Place an X in the appropriate box.)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 25 Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision. (signature of chair of review panel) (printed name of chair) Form 16 Decision of Review Panel Regarding Transfer Back to a Correctional Facility Mental Health Act Sections 33 and 41 The patient (does) (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision.

The review panel has heard and considered the application of (name of applicant) and has decided □ to order that (name of patient) be transferred back to (name of correctional facility). □ to refuse to make an order. □ to cancel the admission certifi cates or renewal certificates, if any. □ to refuse to cancel the admi ssion certificates or renewal certificates for the following reasons: . (Place an X in the appropriate box(es).) Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision. (signature of chair of review panel) (printed name of chair)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 26 Form 17 Decision of Review Panel Regarding Admission Certificates, Renewal Certificates or Community Treatment Orders Mental Health Act Sections 38(1) and (1.1) and 41 (name of formal patient or person who is subject to the community treatment order) □ (does) □ (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision.

The review panel has heard and considered the application of (name of applicant), bearing a relationship of (self, agent, guardian, other (specify)) to (name of formal patient or person who is subject to the community treatment order), and has decided □ to cancel the admission certifi cates or renewal certificates relating to the person named above. □ to refuse to cancel the admi ssion certificates or renewal certificates relating to the person named above for the following reasons: . □ to cancel the community treatment order relating to the person named above. □ to refuse to cancel the commun ity treatment order relating to the person named above for the following reasons: . □ to order the board of the f acility to issue a community treatment order in respect of the formal patient within a reasonable amount of time. (Note: Admission certificates or renewal certificates remain in force until the community treatment order is issued, or until the certificates are cancelled or renewed or expire, whichever occurs first.) (Place an X in the appropriate box(es).) Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 27 (signature of chair of review panel) (printed name of chair) Reporting Obligations: In accordance with

section 41(4) of the Mental Health Act, the review panel is required to provide separate written reasons for its decision if it decides not to cancel admission or renewal certificates or a community treatment order. Form 17.1 Decision of Review Panel Regarding Order for the Board to Issue a Community Treatment Order Mental Health Act Sections 38(1)(

b) and 41 (name of formal patient) (does) (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision.

The review panel has heard and considered the application of (name of applicant), bearing a relationship of (self, agent, guardian, other (specify)) to (name of formal patient), and has decided □ to order the board of the f acility to issue a community treatment order in respect of the formal patient within a reasonable amount of time. (Note: Admission certificates or renewal certificates remain in force until the community treatment order is issued, or until the certificates are cancelled or renewed or expire, whichever occurs first.) □ to refuse to order the boar d of the facility to issue a community treatment order in respect of the formal patient. (Place an X in the appropriate box.) Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision. (signature of chair of review panel) (printed name of chair)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 28 Form 18 Decision of Review Panel Regarding Renewal Certificates and Community Treatment Orders (Deemed Application) Mental Health Act Sections 39 and 41 (name of formal patient or person who is subject to the community treatment order) (does) (does not) object to the nearest relative, (name of nearest relative), receiving notice of the decision. The review panel has heard and considered an application deemed by

section 39 of the Act to have been made by (name of formal patient or person who is subject to community treatment order) and has decided □ to cancel the renewal certific ates relating to the person named above. □ to refuse to cancel the renewal certificates relating to the person named above for the following reasons: . □ to cancel the community treatment order relating to the person named above. □ to refuse to cancel the commun ity treatment order relating to the person named above for the following reasons: . □ to order the board of the f acility to issue a community treatment order in respect of the formal patient within a reasonable amount of time. (Note: Admission certificates or renewal certificates remain in force until the community treatment order is issued, or until the certificates are cancelled or renewed or expire, whichever occurs first.) (Place an X in the appropriate box(es).) Date of decision: This decision may be appealed to the Court of King’s Bench within 30 days after receipt of this decision. (signature of chair of review panel) (printed name of chair)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 29 Form 19 Issuance of Community Treatment Order Mental Health Act

Section 9.1 and 14(1.1)(

a) Written Statement (To be completed by the issuing qualified health professional) To: (name of person subject to the order) of (address) And: (name of person, if any) of (address) who is exercising authority under

section 28(1) of the Act to make treatment decisions on behalf of the person who is subject to the community treatment order And: if the person noted above i s not the nearest relative, (name of nearest relative) of (address) , un less the person subject to the order objects on reasonable grounds And: (name of other person, if any) of (address) designa ted by the person subject to th e order to receive notices: Take notice that (name of person subject to the order) is now subject to a community treatment order pursuant to

section 9.1 of the Act. The reason for the issuance of the community treatment order is (reason in simple language) . Important Information: You have the right to apply to a review panel for cancellation of this community treatment order. You may apply for cancellation of this community treatment order by filing an application with the chair of the review panel. An application may be filed by you, your agent, your guardian or another person on your behalf. _____________________________________ Name of chair of appropriate review panel ________________________________ Contact information of appropriate review panel

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 30 (signature of issuing qualified health professional) (date) (printed name of issuing qualified health professional) (phone number, including extension number, if any) (Either

Part I or

Part II to be completed by a psychiatrist) Community Treatment Order

PART I Issuing Qualified Health Professional’s Examination Name of person: Address (if known): Phone (if known): Date of Birth: Personal Health Number: I, (name of psychiatrist or other qualified health professional) of (business address), (phone number, including extension number, if any), am □ a psychiatrist or I h ave the authority of a psychiatrist for the purposes of the Act by way of a declaration made under

section 49(2) of the Act, o r □ a qualified health professional other than a psychiatrist, and I am the issuing qualified health professional of this community treatment order. I certify that I examined this person on (date) at (time) at (place of examination) with the following results: 1. The person examined (

a) in my opinion, is suffering from mental disorder, (

b) h a s □ during the immediately preceding 3-year period, on 2 or more occasions, or for a total of at least 30 days,

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 31 □ been a formal patient in a facility, □ been in an approved ho spital or been lawfully detained in a custodial institution where there is satisfactory evidence that while there the person would have met the criteria set out in

section 2(

a) and (

c) of the Act at the time or those times, o r □ both been a formal patient in a facility and been in an approved hospital or lawfully detained in a custodial institution where there is satisfactory evidence that while there the person would have met the criteria set out in

section 2(

a) and (

c) of the Act at the time or those times, o r □ within the immediately preceding 3-year period, been subject to a community treatment order, o r □ in my opinion, while living in the community, exhibited a pattern of recurrent or repetitive behaviour that indicates the person is likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, o r □ become the subject of an order made by a review panel for the board to issue a community treatment order, (

c) in my opinion, within a reasonable time, is likely to caus e harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, and (

d) is able to comply with the t reatment or care set out in this community treatment order.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 32 2. The facts on which I formed the above opinions are as follows: 3. I am satisfied that the treatment or care set out in

Part III of this community treatment order exists in the community, is available to the person and will be provided to the person. (signature of issuing (date and time) qualified health professional)

PART II Second Examination by Qualified Health Professional I, (name of psychiatrist or other qualified health professional) of (business address), (phone number, including extension number, if any), am □ a psychiatrist or I h ave the authority of a psychiatrist for the purposes of the Act by way of a declaration made under

section 49(2) of the Act. o r □ a qualified health professional other than a psychiatrist. I certify that I examined this person on (date) at (time) at (place of examination) with the following results: 1. The person examined (

a) in my opinion, is suffering from mental disorder, (

b) h a s □ during the immediately preceding 3-year period, on 2 or more occasions, or for a total of at least 30 days, □ been a formal patient in a facility, □ been in an approved ho spital or been lawfully detained in a custodial institution where there is satisfactory evidence that while there the person would have met the criteria set out in

section 2(

a) and (

c) of the Act at the time or those times, o r

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 33 □ both been a formal patient in a facility and been in an approved hospital or lawfully detained in a custodial institution where there is satisfactory evidence that while there the person would have met the criteria set out in

section 2(

a) and (

c) of the Act at the time or those times, o r □ within the immediately preceding 3-year period, been subject to a community treatment order, o r □ in my opinion, while living in the community, exhibited a pattern of recurrent or repetitive behaviour that indicates the person is likely to cause harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, o r □ become the subject of an order made by a review panel for the board to issue a community treatment order, (

c) in my opinion, within a reasonable time, is likely to caus e harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, and (

d) is able to comply with the t reatment or care set out in this community treatment order. 2. The facts on which I formed the above opinions are as follows: 3. I am satisfied that the treatment or care set out in

Part III of this community treatment order exists in the community, is available to the person and will be provided to the person. (signature of psychiatrist or other qualified (date and time) health professional)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 34

PART III Treatment and Care Plan The person who is subject to this community treatment order must 1. take the following medications (which may be adjusted where indicated by clinical need): □ o r □ see attached list, 2. attend the following appointments with, accept telephone or email contact with or home visits from or receive treatment or care from the following provider(

s) or the provider’s designate: Provider Name: Contact Phone Number (including extension number, if any): Contact Email (optional): Profession/Role: Description of Treatment or Care: Location (if applicable): Date/Time or Frequency (if applicable): (signature of provider or person (date) authorized by provincial health agency, regional health authority or provincial health corporation) (Where treatment or care is provided by a provincial health agency or regional health authority provider, a person authorized by the provincial health agency or regional health authority must sign the Plan before it is issued.

Where treatment or care is provided by a provider other than a provincial health agency or regional health authority provider, that provider must sign the Plan before it is issued.)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 35 Reporting Obligations: In accordance with the Community Treatment Order Regulation, providers of treatment or care to the person who is subject to this community treatment order are required to report any failure by the person who is subject to the community treatment order to comply with the Treatment and Care Plan by (

a) completing Form 25, and (

b) submitting the completed Form 25 to the appropriate provincial health agency within 24 hours of the time at which the provider became aware of the failure to comply.

PART IV Person Responsible for Supervision of Community Treatment Order The person responsible for the supervision of this community treatment order is □ the issuing qualified health professional, or □ (name of qualified health professional who is responsible for the supervision of this community treatment order) . I, (name of qualified health professional) of (business address), (phone number, including extension number, if any), (email address (optional)), am responsible for the supervision of this community treatment order. (signature of supervising qualified health (date) professional)

PART V Consent □ Consent by person who is subject to community treatment order I, _______________________________________, am the person subject to this community treatment order and I consent to the issuing of this community treatment order. (signature) (date) □ Consent by substitute decision-maker

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 36 I, (name of substitute decision-maker) , am the person authorized under

section 28(1) of the Act to make treatment decisions on behalf of the person who is subject to this community treatment order and I hereby consent to the issuing of this community treatment order. (signature of substitute decision-maker) (date) □ No consent We, the issuing qualified health professionals, have not obtained consent to the issuing of this community treatment order.

We are of the opinion that the person who is subject to this community treatment order has, while living in the community, exhibited a history of not obtaining or continuing with treatment or care that is necessary to prevent the likelihood of harm to others or negative effects to the person, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, and the issuance of a community treatment order is reasonable in the circumstances and would be less restrictive than retaining the person as a formal patient. (signature of issuing qualified (date) health professional) (signature of psychiatrist or other (date) qualified health professional who completed

Part II) Form 20 Renewal of Community Treatment Order Mental Health Act

Section 9.3 and 14(1.1)(

a) Written Statement (To be completed by the issuing qualified health professional) To: (name of person subject to the order) of (address) And: (name of person, if any) of (address) who is exercising authority under

section 28(1) of the Act to make treatment decisions on behalf of the person who is subject to the community treatment order

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 37 And: if the person noted above i s not the nearest relative, (name of nearest relative) of (address) , unless the p erson subject to the order objects on reasonable grounds And: (name of other person, if any) of (address) designa ted by the person subject to th e order to receive notices: Take notice that the community treatment order of (name of person subject to the order) has been renewed under

section 9.3 of the Act. The reason for the renewal of the community treatment order is (reason in simple language) . Important Information: You have the right to apply to a review panel for cancellation of this community treatment order. You may apply for cancellation of this community treatment order by filing an application with the chair of the review panel.

An application may be filed by you, your agent, your guardian or another person on your behalf. _____________________________________ Name of chair of appropriate review panel ________________________________ Contact information of appropriate review panel (signature of issuing qualified health professional) (date) (printed name of issuing qualified health professional) (phone number, including extension number, if any) (Either

Part I or

Part II to be completed by a psychiatrist) Community Treatment Order

PART I Issuing Qualified Health Professional’s Examination Name of person: Address (if known): Phone (if known): Date of Birth: Personal Health Number:

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 38 I, (name of psychiatrist or other qualified health professional) of (business address), (phone number including extension number, if any), am □ a psychiatrist or I have the authority of a psychiatrist for the purposes of the Act by way of a declaration made under

section 49(2) of the Act, o r □ a qualified health professional other than a psychiatrist, and I am the issuing qualified health professional in relation to the renewal of this community treatment order. I certify that I examined this person on (date) at (time) at (place of examination) with the following results: 1. The person examined (

a) in my opinion, continues to suffer from mental disorder, (

b) is currently subject to a community treatment order, (

c) in my opinion, within a reasonable time, is likely to caus e harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, and (

d) is able to comply with the t reatment or care set out in this community treatment order. 2. The facts on which I formed the above opinions are as follows: 3. I am satisfied that the treatment or care set out in

Part III of this renewal exists in the community, is available to the person and will be provided to the person. (signature of issuing (date and time) qualified health professional)

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 39

PART II Second Examination by Qualified Health Professional I, (name of psychiatrist or other qualified health professional) of (business address), (phone number, including extension number, if any), am □ a psychiatrist or I h ave the authority of a psychiatrist for the purposes of the Act by way of a declaration made under

section 49(2) of the Act. o r □ a qualified health professional other than a psychiatrist. I certify that I examined this person on (date) at (time) at (place of examination) with the following results: 1. The person examined (

a) in my opinion, continues to suffer from mental disorder, (

b) is currently subject to a community treatment order, (

c) in my opinion, within a reasonable time, is likely to caus e harm to others or to suffer negative effects, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, if the person does not receive continuing treatment or care while living in the community, and (

d) is able to comply with the t reatment or care set out in this community treatment order. 2. The facts on which I formed the above opinions are as follows: 3. I am satisfied that the treatment or care set out in

Part III of this renewal exists in the community, is available to the person and will be provided to the person. (signature of psychiatrist or other (date and time) qualified health professional)

PART III Treatment and Care Plan The person who is subject to this community treatment order must

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 40 1. take the following medications (which may be adjusted where indicated by clinical need): □ o r □ see attached list, 2. attend the following appointments with, accept telephone or email contact with or home visits from or receive treatment or care from the following provider(

s) or the provider’s designate: Provider Name: Contact Phone Number (including extension number, if any): Contact Email (optional): Profession/Role: Description of Treatment or Care: Location (if applicable): Date/Time or Frequency (if applicable): (signature of provider or person (date) authorized byprovincial health agency or regional health authority) (Where treatment or care is provided by a provincial health agency or regional health authority provider, a person authorized by the provincial health agency or regional health authority must sign the Plan before it is issued.

Where treatment or care is provided by a provider other than a provincial health agency or regional health authority provider, that provider must sign the Plan before it is issued.) Reporting Obligations: In accordance with the Community Treatment Order Regulation, providers of treatment or care to the person who is subject to this community treatment order are required to report any failure by the person who is subject to the community treatment order to comply with the Treatment and Care Plan by (

a) completing Form 25, and (

b) submitting the com pleted Form 25 to the appropriate provincial health agency within 24 hours of the time at which the provider became

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 41 aware of the failure to comply.

PART IV Person Responsible for Supervision of Community Treatment Order The person responsible for the supervision of this community treatment order is □ the issuing qualified health professional, or □ (name of qualified health professional who is responsible for the supervision of this community treatment order) . I, (name of qualified health professional), of (business address), (phone number, including extension number, if any), (email address (optional)), am responsible for the supervision of this community treatment order. (signature of supervising qualified health (date) professional)

PART V Consent □ Consent by person who is subject to community treatment order I, _______________________________________, am the person subject to this community treatment order and I consent to the renewal of this community treatment order. (signature) (date) □ Consent by substitute decision-maker I, (name of substitute decision-maker) , am the person authorized under

section 28(1) of the Act to make treatment decisions on behalf of the person who is subject to this community treatment order and I hereby consent to the renewal of this community treatment order. (signature of substitute decision-maker) (date) □ No consent

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 42 We, the issuing qualified health professionals, have not obtained consent to the renewal of this community treatment order.

We are of the opinion that the person who is subject to this community treatment order has, while living in the community, exhibited a history of not obtaining or continuing with treatment or care that is necessary to prevent the likelihood of harm to others, or negative effects to the person, including substantial mental or physical deterioration or serious physical impairment, as a result of or related to the mental disorder, and the renewal of the community treatment order is reasonable in the circumstances and would be less restrictive than retaining the person as a formal patient. (signature of issuing qualified (date) health professional) (signature of psychiatrist or other (date) qualified health professional who completed

Part II) Form 21 Community Treatment Order Amendments to Community Treatment Order Mental Health Act

Section 9.4 and 14(1.1)(

a) Written Statement (To be completed by the issuing qualified health professional) To: (name of person subject to the order) of (address) And: (name of person, if any) of (address) who is exercising authority under

section 28(1) of the Act to make treatment decisions on behalf of the person who is subject to the community treatment order And: if the person noted above i s not the nearest relative, (name of nearest relative) of (address) , unless the person subject to the order objects on reasonable grounds And: (name of other person, if any) of (address) designa ted by the person subject to th e order to receive notices:

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 43 Take notice that the community treatment order of (name of person subject to the order) has been amended pursuant to

section 9.4 of the Act. The reason for the amendment of the community treatment order is (reason in simple language) . Important Information: You have the right to apply to a review panel for cancellation of this community treatment order. You may apply for cancellation of this community treatment order by filing an application with the chair of the review panel.

An application may be filed by you, your agent, your guardian or another person on your behalf. _____________________________________ Name of chair of appropriate review panel ________________________________ Contact information of appropriate review panel (signature of issuing qualified (date) health professional) (printed name of issuing qualified health professional) (phone number, including extension number, if any) Community Treatment Order Amendments Name of person: Address (if known): Phone (if known): Date of birth: Personal Health Number: I, (name of qualified health professional), of (business address), (phone number, including extension number, if any), am the issuing qualified health professional of this amended community treatment order.

I amend the community treatment order for this person by □ amending the name of the person responsible for supervision of the community treatment order as follows: Effective on the date below I, (name of qualified health professional), of (business address), (phone number,

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 44 including extension number, if any), (email address (optional)), am responsible for the supervision of this community treatment order. (signature of supervising (effective date) qualified health professional) □ amending the treatment and care plan as follows: The person who is subject to this community treatment order must 1. take the following medications (which may be adjusted where indicated by clinical need): □ o r □ see attached list, 2. attend the following appointments with, accept telephone or email contact with or home visits from or receive treatment or care from the following provider(

s) or the provider’s designate: Provider Name: ________________________________ Contact Phone Number (including extension number, if any): Contact Email (optional): Profession/Role: ________________________________ Description of Treatment or Care: Location (if applicable): Date/Time or Frequency (if applicable): (signature of provider or person (date) authorized by prov incial health agency or regional health authority) (Where treatment or care is provided by a provincial health agency or regional health authority provider, a person authorized by the provincial health agency or regional health authority must sign the Plan before it is issued.) 3. the person who is subject to the community treatment order is no longer required to .

I have explained the above amendment(

s) to

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 45 □ the person who is subject to this community treatment order. or □ the substitute decision-maker for the person who is subject to this community treatment order. (signature of issuing qualified (date) health professional) Reporting Obligations: In accordance with the Community Treatment Order Regulation, providers of treatment or care to the person who is subject to this community treatment order are required to report any failure by the person who is subject to the community treatment order to comply with the Treatment and Care Plan by (

a) completing Form 25, and (

b) submitting the completed Form 25 to the appropriate provincial health agency within 24 hours of the time at which the provider became aware of the failure to comply. Form 22 Community Treatment Order Cancellation or Expiry Mental Health Act Sections 9.2, 9.5 and 14(5) Name of person: Address (if known): Phone (if known): Date of Birth: Personal Health Number: (Either

Part I or

Part II is to be completed)

PART I Cancellation I, (name of psychiatrist or authorized person), of (business address), (phone number, including extension number, if any), am a psychiatrist or I have the authority of a psychiatrist for the purposes

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 46 of the Act by way of a declaration made under

section 49(2) of the Act. □ I cancel this person’s community treatment order because this person no longer meets the criteria specified in

section 9.1(1)(

b) to (

d) of the Act. Continued treatment recommendation (if applicable): I recommend continued treatment and care as follows: ______________________________________________________ (signature of psychiatrist or authorized person) (date and time ) (printed name of psychiatrist or authorized person)

PART II Expiry □ This person’s community treatment order has expired. Continued treatment recommendation (if applicable): I recommend continued treatment and care as follows: ______________________________________________________ (signature of qualified health professional) (date and time) (printed name of qualified health professional) Notice: You are no longer subject to a community treatment order effective on the date and time written above. However, this form may contain information about treatment and care that your health care provider is recommending you continue to receive.

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 47 Form 23 Community Treatment Order Apprehension Order Mental Health Act

Section 9.6 To all or any peace officers in Alberta: Name of person: Address (if known): Phone (if known): Date of birth: I, (name of qualified health professional), of (business address), (phone number, including extension number, if any), have reasonable grounds to believe that (name of person who is subject to community treatment order) has failed to comply with their community treatment order. The reasons for my belief are as follows: . I am satisfied that efforts that are reasonable in the circumstances have been made to (

a) inform the person who is named in this order that the person has failed to comply with the person’s community treatment order, (

b) inform the person of the possibility that I may issue an order for apprehension and assessment of the person if the person continues to fail to comply with the community treatment order, and of the possible consequences of that assessment, and (

c) provide reasonable assistance to the person to comply with the community treatment order and that the person continues to fail to comply with the community treatment order. This authorizes you to (

a) apprehend the person who is named in this order and to convey the person to (name of facility) for an examination,

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 48 (

b) take reasonable measures, including the entering of premises and the use of physical restraint, to apprehend the person who is named in this order and to take the person into custody for the purpose of conveying the person to the facility, and (

c) while the person is being conveyed to the facility, to car e for, observe, detain and control the person. (signature of qualified health professional) (date and time) This apprehension order expires 30 days after the date of issue. Form 24 Community Treatment Order Examination on Apprehension Mental Health Act

Section 9.6 Name of person: Address (if known): Phone (if known): Date of birth: Personal Health Number: I, (name of psychiatrist or other qualified health professional) of (business address), (phone number, including extension number, if any), am □ a psychiatrist or I h ave the authority of a psychiatrist for the purposes of the Act by way of a declaration made under

section 49(2) of the Act, or □ a qualified health professional other than a psychiatrist. I certify that I examined this person on (date) at (time) at (place of examination) and have determined that □ the person’s community treatment order should be cancelled and the person should be released without being subject to a community treatment order (a psychiatrist must also complete Form 22), or □ the person’s community treatment order should be continued and amendments to it are not necessary, or

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 49 □ the person’s community treatment order should be continued but amendments to it are necessary (also complete Form 21), or □ the person’s community treatment order should be cancelled and admission certificates issued in accordance with sections 2 and 6 of the Act (also complete Form 1). (Note: Select one.) (signature of psychiatrist or other (date and time) qualified health professional) Form 25 Community Treatment Order Non-compliance Report Mental Health Act

Section 9.1(2)(

f) Name of person: Address (if known): Phone (if known): Date of Birth: Personal Health Number: The person who is subject to this community treatment order has failed to comply with the following requirements of the treatment or care plan on the dates specified: Date: _____________ Treatment or Care: Date: _____________ Treatment or Care: (signature of treatment or care provider) (date) (printed name of treatment or care provider) (phone number, including extension number, if any) Reporting Obligations: In accordance with the Community Treatment Order Regulation, providers of treatment or care to the person who is subject to this community treatment order are required to report any failure by the person who is subject to the community treatment order to comply with the Treatment and Care Plan

Schedule AR 136/2004 MENTAL HEALTH ACT FORMS AND DESIGNATION REGULATION 50 by (

a) completing Form 25, and (

b) submitting the completed Form 25 to the appropriate provincial health agency within 24 hours of the time at which the provider became aware of the failure to comply. Form 26 Repealed AR 115/2021 s4. AR 136/2004 Sched;183/2020;115/2021;191/2022; 216/2022;218/2022;76/2023;125/2024;126/2024; 199/2025;268/2025

Printed on Recycled Paper *9780779859672*

Document details

Collection	Alberta — Regulations
Citation	Alta. Reg. 136/2004
Type	regulation
Volume / chapter	2004 136
Language	en
Format	pdf
Source	PROVINCIAL
Identifier	56e13ce9f944513db61e2fe989a5599d6aeed763

Source file is stored in the law ingest library (pdf).