Mental Health Act Forms

Patient Rights

Form 1 - Notification of Patient Rights and Other Information

Involuntary Assessment and Admission

Form 2 - Certificate of Involuntary Assessment

Form 3 - Certificate of Involuntary Admission

Form 4 - Renewal Certificate

Form 5 - Cancellation of Certificate of Involuntary Admission or of Renewal Certificate

Person to Receive Information

  • Form 6 - Designation of Person to Receive Information

Transfer Authorizations

Form 7 - Authorization to Transfer Involuntary Patient to Facility within the Northwest Territories

Form 8 - Certificate Authorizing Transfer of Involuntary Patient to Facility outside the Northwest Territories

Form 9 - Authorization to Transfer a Patient to a Designated Facility from a Health Facility outside the Northwest Territories

Statement for Apprehension or Conveyance

Form 10 - Summary Statement Respecting Apprehension or Conveyance

Competency to Make Treatment Decisions

Form 11 - Treatment Decision Certificate

Form 12 - Designation of Substitute Decision Maker

Form 13 - Cancellation of Treatment Decision Certificate

Competency to Manage Estate

Form 14 - Certificate of Mental Incompetence

Form 15 - Cancellation of Certificate of Mental Incompetence

Short Term Leave 

  • Form 16 - Short Term Leave Certificate

  • Form 17 - Cancellation of Short Term Leave Certificate

Assisted Community Treatment

Form 21 - Notice of Intention to Issue Assisted Community Treatment Certificate

Form 22 - Assisted Community Treatment Certificate

Form 23 - Community Treatment Plan

  • English | French

    • Monitor Form - Community Treatment Plan – Consent of Monitor

    • Provider Form - Community Treatment Plan – Consent of Provider

    • Consent Form - Community Treatment Plan – Patient Consent

Form 24 - Community Treatment Plan Report

Form 25 - Assisted Community Treatment Certificate, Amendment

Form 26 - Community Treatment Plan, Amendment

Form 27 - Certificate Requiring Patient to Attend Mandatory Assessment at Health Facility

Form 28 - Certificate Cancelling Assisted Community Treatment Certificate

Form 29 - Notice Requiring Patient to Return to Designated Facility on Expiration of Assisted Community Treatment Certificate

Unauthorized Absence

Form 18 - Unauthorized Absence Statement

Review Board

  • Form 19 - Application to Review Board

  • Form 20 - Notice to Review Board