Mental Health Act Forms
Patient Rights
Form 1 - Notification of Patient Rights and Other Information
- English | French
Involuntary Assessment and Admission
Form 2 - Certificate of Involuntary Assessment
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English | French
Form 3 - Certificate of Involuntary Admission
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English | French
Form 4 - Renewal Certificate
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English | French
Form 5 - Cancellation of Certificate of Involuntary Admission or of Renewal Certificate
- English | French
Person to Receive Information
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Form 6 - Designation of Person to Receive Information
- English | French
Transfer Authorizations
Form 7 - Authorization to Transfer Involuntary Patient to Facility within the Northwest Territories
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English | French
Form 8 - Certificate Authorizing Transfer of Involuntary Patient to Facility outside the Northwest Territories
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English | French
Form 9 - Authorization to Transfer a Patient to a Designated Facility from a Health Facility outside the Northwest Territories
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English | French
Statement for Apprehension or Conveyance
Form 10 - Summary Statement Respecting Apprehension or Conveyance
- English | French
Competency to Make Treatment Decisions
Form 11 - Treatment Decision Certificate
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English | French
Form 12 - Designation of Substitute Decision Maker
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English | French
Form 13 - Cancellation of Treatment Decision Certificate
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English | French
Competency to Manage Estate
Form 14 - Certificate of Mental Incompetence
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English | French
Form 15 - Cancellation of Certificate of Mental Incompetence
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English | French
Short Term Leave
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Form 16 - Short Term Leave Certificate
- English | French
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Form 17 - Cancellation of Short Term Leave Certificate
- English | French
Assisted Community Treatment
Form 21 - Notice of Intention to Issue Assisted Community Treatment Certificate
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English | French
Form 22 - Assisted Community Treatment Certificate
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English | French
Form 23 - Community Treatment Plan
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English | French
Form 24 - Community Treatment Plan Report
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English | French
Form 25 - Assisted Community Treatment Certificate, Amendment
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English | French
Form 26 - Community Treatment Plan, Amendment
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English | French
Form 27 - Certificate Requiring Patient to Attend Mandatory Assessment at Health Facility
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English | French
Form 28 - Certificate Cancelling Assisted Community Treatment Certificate
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English | French
Form 29 - Notice Requiring Patient to Return to Designated Facility on Expiration of Assisted Community Treatment Certificate
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English | French
Unauthorized Absence
Form 18 - Unauthorized Absence Statement
- English | French
Review Board
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Form 19 - Application to Review Board
- English | French
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Form 20 - Notice to Review Board
- English | French