Mental Health Act Application by Physician for Psychiatric Assessment - Form 1 and 42 (Auto-Populated)

Oct 5, 2026

Psychiatric patient assessment forms for emergency department use require clinicians to document vital sign status, reviewed high-risk features, ordered investigations, and completion of interim medication-related orders for every ED patient prior to PERT/Psychiatry. The forms include physician comments guiding appropriate re-assessment if the patient condition changes, and sections for serious harm testing under Mental Health Act provisions. They also specify criteria for patients incapable of consenting to treatment and requesting substitute decision-maker authorization, including evidence sources and physician application for psychiatric assessment.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages7

Reading Time18 min

AccessFree to download

Vital Signs and Monitoring

High Risk Features Reviewed

Investigations and Interim Orders

Patient Stability for Transfer

Serious Harm Test (Section 15(1))

Information Sources and Observations

Incapable of Consenting to Treatment (Section 15(1.1))

Prior Treatment, Criteria, and Likely Outcomes

Rev . 11/2022(v1) PERT / Psychiatric Patient Assessment Form Emergency Department To be completed for every ED patient before TOC to PERT / Psychiatry | Item | Check | | --- | --- | | 1. Vital Signs (temp, pulse, RR, B/P, O−Sat plus Finger Glucose in altered patient): | | | ● Vital signs are normal / at baseline | | | ● Vital signs are abnormal but appropriate for patient condition (appropriate testing that is clinically indicated has been completed) .
Nursing staff to continue to monitor Vital Signs. If they worsen or do not improve, inform MRP. | | | 2. High Risk features have been reviewed and addressed as clinically indicated: | | | ● Acute / New onset | | | ● Visual Hallucinations | | | ● Inability to complete a reasonable history | | | ● History suggestive of life−threatening ingestion / overdose | | | ● First incidence of psychiatrically altered patient, especially over 55 years of age | | | ● Medications reviewed especially for new medications | | | ● Altered sensorium, especially fluctuation of delirium, unexplained | | | ● Seizure, including tongue biting | | | ● Recent trauma | | | ● Concern for infection (including IVDU) | | | ● Abnormal focused examinations | | | ● Immunodeficiency | | | 3. Investigations ordered have been reviewed: | | | ● Yes | | | ● Some are pending (non−critical) and I will follow up on them | | | 4. Interim orders for regular medications, NRT, chemical restraints etc. completed | | | ● Yes | | | 5. This patient is: | | | ● SCS: Stable for transfer to PERT | | | ● NFS, WS: Stable for PERT / Psychiatrist assessment | | Comments from ED Physician: NOTES: ● Initial Emergency Medicine assessment is not intended to rule out every concomitant medical condition. If the patient situation changes, please inform MRP. ● The psychiatrist is encouraged to consult any appropriate service (Emergency Medicine included) if clinically indicated at any time in the journey of the patient. Emergency Physician Name / Signature h!33SST􀀑103􀀐􀀓Ayz Chart Copy − Do Not Date / Time (dd/mm/yyyy hh:mm) Destroy Page 1 of 1 Dr. Rafi F Setrak 01/May/2023 12:24 Ministry of Health Form 1 Mental Health Act Application by Physician for Psychiatric Assessment This auto-populated version of the Form 1 and 42 is only to be used within psychiatric facilities where the Form 42 will be immediately issued to the recipient by the same physician that is completing the Form 1. Please note that there is a print button at the end of the form. This form will only print once all mandatory fields are completed. Clear Form |
Facts communicated to me by others:
The Future Test (check one or more)
I am of the opinion that the person is apparently suffering from mental disorder of a nature or quality that likely will result in: | | | --- | --- | | | serious bodily harm to himself or herself, serious bodily harm to another person, serious physical impairment of himself or herself | 6427–41 (2000/12) (Disponible en version française) See reverse 􀀂Queen’s Printer for Ontario, 2000 7530–4972 Box A – Section 15(1) of the Mental Health Act Serious Harm Test (continued) I base this opinion on the following information (you may, as appropriate in the circumstances, rely on any combination of your own observations and information communicated to you by others.) My own observations: * Facts communicated by others: Box B – Section 15(1.1) of the Mental Health Act Patients who are Incapable of Consenting to Treatment and Meet the Specified Criteria Note: The patient must meet the criteria set out in each of the following conditions. I have reasonable cause to believe that the person: 1. Has previously received treatment for mental disorder of an ongoing or recurring nature that, when not treated, is of a nature or quality that likely will result in one or more of the following: (please indicate one or more) serious bodily harm to himself or herself, serious bodily harm

FAQs

What must be completed for every ED patient before PERT/Psychiatry?

Clinicians must complete checks for vital signs, review high-risk features, confirm investigations status, and ensure interim orders for regular medications and restraints are completed as indicated. Patient stability for transfer should also be documented.

How are “high risk features” defined on the form?

High risk features include acute/new onset, visual hallucinations, inability to complete a reasonable history, suspected life-threatening ingestion/overdose, first psychiatric alteration especially over 55, and other serious clinical concerns such as delirium fluctuation or recent trauma.

What criteria are required for patients incapable of consenting to treatment?

The form requires that the person meets specified conditions, including prior treatment for an ongoing/recurring mental disorder with likely serious outcomes when untreated, clinical improvement with treatment, incapacity to consent under the Health Care Consent Act, and likely risk of serious harm or deterioration based on history and current condition.

Oct 5, 2026

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