Scribd
Upload
279 views1 page

Mental Health Consent Form

This document is a consent form for treatment under the Mental Health Act for involuntary patients. It allows either the patient or an authorized director to authorize treatment after explaining the nature of the condition and treatment options. The form requires signatures from the patient, director, witnesses, and physicians to validate the consent process.

Uploaded by

Noreen Punjwani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
279 views1 page

Mental Health Consent Form

This document is a consent form for treatment under the Mental Health Act for involuntary patients. It allows either the patient or an authorized director to authorize treatment after explaining the nature of the condition and treatment options. The form requires signatures from the patient, director, witnesses, and physicians to validate the consent process.

Uploaded by

Noreen Punjwani
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

FORM 5

MENTAL HEALTH ACT


[ Sections 8 and 31, R.S.B.C. 1996, c. 288 ]

CONSENT FOR TREATMENT


(INVOLUNTARY PATIENT)

Note: Complete either A or B

A. I, , authorize the treatment described below.


first and last name of patient (please print)

B. I, , authorize the treatment described below


name of director or person authorized by the director (please print)

with respect to at .
first and last name of patient name of designated facility (please print)

Description of treatment/course of treatment:

The nature of the condition, options for treatment, the reasons for and the likely benefits and risks of the treatment
described above have been explained to me by .
name and position/title

Complete either A or B
A. If signed by patient B. If not signed by patient

patient's signature signature

name of director or person authorized by the director (please print)

date (dd / mm / yyyy) time

position/title

witness’ signature
date (dd / mm / yyyy) time

witness’ first and last name (please print) The above-named patient is an involuntary patient under
section 22, 28, 29, 30, or 42 of the Mental Health Act and to
To the best of my judgment, the above-named patient was the best of my judgment is incapable of appreciating the
capable of understanding the nature of the above nature of treatment and/or his or her need for it, and is there-
authorization at the time it was signed. fore incapable of giving consent.

, M.D. , M.D.
signature of physician signature of physician
HLTH 3505 Rev. 2005/06/01

PRINT CLEAR FORM

You might also like