Primer
A Form 4 (Medical Certificate for Involuntary Admission), is a form under the British Columbia Mental Health Act that allows a person to be apprehended, transported, admitted, treated, and detained as an involuntary patient for up to 48 hours. A second Form 4 (Form 4.2) can be completed to extend the involuntary hospitalization for up to 1 calendar month starting from the date of involuntary admission. Nurse practitioners are now able to issue a Form 4.1 (i.e. - the 1st Form 4), as of February 1, 2023 in British Columbia. A Form 4.2 continues to require an assessment and sign-off by a physician.
Voluntary Admissions
Patients need not always be admitted involuntarily for psychiatric disorders. If a patient is willingly coming into the hospital, they can be admitted in one of two ways:
Under British Columbia's Hospital Act, which does not require the use of mental health forms. In routine clinical practice, this is the most common way of admitting voluntary patients as there is no paperwork required.
Or, a patient could also be admitted voluntarily under British Columbia's Mental Health Act, but this would require giving the patient a
Form 1 (Request for Admission) and
Form 2 (Consent for Treatment) In routine clinical practice, this is rarely done except for individuals under age 16.
Law Enforcement
Police officers have powers under Section 28 of the MHA to take an individual into custody and to transport them to a designated facility for assessment by a physician who will determine the need for further treatment. The criteria used by the police are:
If the person is acting in a manner likely to endanger that person's own safety or the safety of others; and
If the person is apparently a person with a mental disorder.
Upon arrival, police must keep the person in their custody until the individual is examined by a physician.
Involuntary Admission Criteria
In order for an individual to be admitted involuntarily, all of the following four criteria must be met; a physician must be of the opinion that an individual:
Is suffering from an apparent mental disorder that seriously impairs their ability to react appropriately to his or her environment or to associate with others;
Requires psychiatric treatment in or through a designated facility
Requires care, supervision, and control in (or through) a designated facility to prevent the person's substantial mental or physical deterioration, or for the person's own protection, or for the protection of others; and
Is not suitable as a voluntary patient
If all of the above criteria is met, a Form 4 must be completed by a physician licensed to practice medicine in British Columbia. The physician does not need to be a psychiatrist. A resident physician (i.e. - educational license) is not legally allowed to complete a Form 4.
What does 'Protection' Mean?
Protection as defined by BC law includes not just physical protection, but also social, family, work, or financial life of the patient.
Old Form 4
The old Form 4 will continue to be legally valid for physicians to complete until February 1, 2024, after which point Form 4.1 and Form 4.2 must be used.
The physician or nurse practitioner must complete the Form 4 as soon as possible after the examination/assessment of the patient, collection of collateral information and completion of necessary investigations to determine that the patient meets the criteria for treatment under the Mental Health Act.
A Form 4 does not have to be issued immediately – for example, if additional collateral information is needed, a physician has up to 14 days from the date which they have examined the patient to decide whether they want to initiate a the first Form 4.
If a physician has filled out a certificate, and the patient cannot be found, the certificate is still valid for 14 days starting from the time it was filled out.
Thus, a Form 4 can also be used to recall a previously voluntary patient who has left, and have police take them back to a designated hospital facility if there is concern about the patient harming themselves or others.
Once a patient is involuntarily admitted to hospital, a second physician's examination and second Form 4 must be completed within 48 hours.
The 2nd Form 4 continues the involuntary hospitalization for up to 1 calendar month starting from the date of involuntary admission (see section below for further clarification).
Normally, it is typical (but not necessary) that two medical certificates (i.e. - two Form 4s) should be in place before treatment starts.
If a second Form 4 is not completed within 48 hours, the patient must be discharged or admitted as a voluntary patient.
How Long Does the Second Form 4 Last?
“Irrespective of the duration of the involuntary admission, Forms 4, 5, 13, 15 and 16 must be completed.”
– Office of Ombudsperson Province of British Columbia Report: Committed to Change: Protecting the Rights of Involuntary Patients under the Mental Health Act
The following Forms must be completed immediately on admission, regardless of the length of a patient's involuntary admission:
Admission
Date of Involuntary Admission
The 'date of involuntary admission' is the key date from which all future periods of involuntary hospitalization are derived.
This is the date on which an individual has been admitted to a designated facility with a first Form 4
Thus, this is not necessarily the date that the patient arrived at the hospital! (e.g. - they may have been voluntary for a period time before being on a Form 4)
It is also not necessarily the date that a Form 4 was completed either! (e.g. - the patient may have been seen in an outpatient office, and the physician may have issued a Form 4 the same day, but the patient did not arrive and become admitted at the hospital until 3 days later)
There can often be confusion and misunderstanding by clinicians over what constitutes the date of involuntary admission.
'Date of Involuntary Admission' Example
Jane Doe brought herself to hospital on January 5th with persecutory delusions. She came to the hospital seeking help, and was thus admitted voluntarily.
One week later, on January 12th, she started to become paranoid about staff on the unit and requested to be discharged from hospital.
She was assessed by two psychiatrists in hospital and two
Form 4s (i.e. - Medical Certificate for Involuntary Admission), were completed on
January 12th (the same day).
It is now February 1st and she is approaching the 1-month period of being in hospital but she has not improved and continues to meet all 4 criteria for certification.
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Since the date of renewal is based on the date of involuntary admission to hospital it is important to remember she did not become involuntary until January 12th. The first week of admission was voluntary, so she has been certified and involuntarily admitted only since January 12th.
This means her second Form 4 will last until February 11th 11:59pm, and expires on February 12th (the moment the clock strikes at midnight!)
Practically speaking, you must then complete the Form 6 at some point on February 11th at the latest.
Admission Length
Example
Action | Form to Fill | Length of Involuntary Admission | Form to Give to Patient | Begins | Expires |
Involuntary Hospitalization Date | - | - | - | March 15, 2020 (AKA - involuntary hospitalization date) | - |
1st Medical Certificate | Form 4 | 48 hours | Form 13 | March 15, 2020 | 48 hours after March 15, 2020 |
2nd Medical Certificate | Form 4 | 1 month from involuntary hospitalization date (minus 1 day) | Form 13 | March 15, 2020 | April 14, 2020 @11:59pm |
1st Renewal | Form 6 | 1 month (minus 1 day) | Form 13 | April 15, 2020 | May 14, 2020 @11:59pm |
2nd Renewal | Form 6 | 3 months (minus 1 day) | Form 13 | May 15, 2020 | August 14, 2020 @11:59pm |
3rd Renewal and Additional Renewals | Form 6 | 6 months (minus 1 day) | Form 13 | August 15, 2020 | Feb 14, 2021 @11:59pm |
When There Is No Corresponding Renewal Date
When there is no corresponding date in the month the certificate/renewal ends, the Interpretation Act in BC directs that the last day of that month be used.
For example, if two Form 4s are completed for an involuntary admission beginning on January 31, 2021, there is no February 31st, 2021!
In these cases, the last day of the following month will be used
Thus, the 1 month period of hospitalization will end at midnight on February 28, 2021 (or 29 in a leap year), following the “last day of the month” rule.
If the patient continues to require involuntary hospitalization, the subsequent first renewal (Form 6) will begin on March 1, 2021, and will end on on March 31, 2021 (i.e. - one month less a day)
From that point on, all future renewals take effect from the 1st of the month in perpetuity (e.g. - second renewal (Form 6), will start April 1, 2021, and ends June 30, 2021).
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