Form 4 (British Columbia - Medical Certificate for Involuntary Admission)

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 can be completed to extend the involuntary hospitalization for up to 1 calendar month starting from the date of involuntary admission.

Download Form 4

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:

  1. 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.
  2. 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.

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:

  1. If the person is acting in a manner likely to endanger that person's own safety or the safety of others; and
  2. 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.

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:

  1. 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;
  2. Requires psychiatric treatment in or through a designated facility
  3. 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
  4. 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.[1]
  • The physician 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.
    • Admission and treatment can then occur under the first Form 4, but some physicians may wait until the second Form 4 has been completed.
  • 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.
    • This must be a different physician from the first Form 4.
  • 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?

  • All together, two completed medical certificates (i.e. - two Form 4s) are good for one month from the date of involuntary admission
  • A calendar month is considered 1 month minus 1 day under BC law. Thus, if an individual received the first Form 4 (initial certification) on May 23 and then received a second Form 4, this means their entire admission could last until midnight on June 22 (i.e. - on June 22 at 11:59pm). The moment the clock hits midnight, and it becomes June 23, 2013, the patient can no longer be involuntarily admitted (unless a Form 6 is issued beforehand).
“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[2]

The following Forms must be completed immediately on admission, regardless of the length of a patient's involuntary admission:

    • This Form sets out why the patient can be involuntarily admitted for up to 48 hours
    • This Form sets out the proposed psychiatric treatment, and either the patient or director must consent before treatment begins
    • This Form provides information about patient’s rights and must be read to the patient and a copy provided to them
    • If a patient is not capable of understanding the Form 13 on admission, the Form must be provided again once patient is capable of understanding. The physician should document that the patient was not capable of understanding the Form 13.
    • This Form allows a patient to nominate a near relative to be notified of admission and detention
    • This Form notifies the near relative of the patient’s admission, detention and rights. If there is no known near relative, form is sent to Public Guardian and Trustee.
  • 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.
  • Now, when is the Form 6 (Medical Certificate for Involuntary Admission) due? (Or put into other words, when does the second Form 4 expire?)
  • 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.

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).
  • For further clarity and a detailed table of dates, refer to Table 1: Renewing Involuntary Status, Guide to the Mental Health Act (pg. 83)