May 2019 By PsychDB.com

Form 1 and Form 42 (Psychiatric Assessment)

A Form 1 (Application by Physician for Psychiatric Assessment) is a provision under the Ontario Mental Health Act that allows a physician to detain a patient for a psychiatric assessment for up to 72 hours at a Schedule 1 Facility. A Form 42 (Notice to Person) is always given to a patient to notify them that they are under a Form 1.

Since a Form 1 is not an involuntary admission per se, the threshold to issue a Form 1 can be low. In order for a Form 1 to be valid, there needs to be evidence of risk and evidence of a mental disorder that is related to that risk. There does not need an actual psychiatric diagnosis or formal psychiatric assessment for a Form 1 to be valid. A mental disorder is defined as any psychiatric disorder and neurocognitive disorder (including dementia and other neurodegenerative disorders).

Box A Criteria

Most physicians will issue a Form 1 based on Box A (“Serious Harm Test”) criteria. The patient must meet at least 1 out of 3 criteria:

  1. Harm to Self (e.g. - suicide)
  2. Harm to Others
    • Physical Harm (e.g. - throwing, spitting, punching), OR
    • Psychological Harm, but the threshold is much higher (e.g. - pacing all night, psychotic, demanding, and parents are locking themselves in bedroom. If threats are enough to intimidate the family member, particularly if there is a history of violence)
  3. Physical Impairment (e.g. - risk of death by not eating, kidney failure by not drinking, untreated infection)

In addition to meeting at least 1 out of 3 criteria, the Form 1 can only valid if there is evidence of a mental disorder. This evidence is based on two “tests”:

  1. Past/Present Test (Risk), and
  2. Future Test (Evidence of Mental Disorder)

Box A Criteria: Past/Present Test and Future Test

Past/Present Test (Risk) Future Test (Evidence of Mental Disorder)
What it means
  • This is where you document the evidence of risk or dangerous behaviour
  • This is where you document the evidence to support findings of a mental disorder that is causing the risk you mentioned
My own observations
  • Think of this as the "History of Presenting Illness"
  • Examination may (and can) be brief. (For example, if the patient is uncooperative or dismissive, can document this)
  • Again, evidence or even mentioning of mental disorder NOT required in this section
  • Mention any dangerous behaviour or evidence of inability to care for self as you are assessing the patient right now
  • Example: Patient screaming at nurse and pacing down hallway, yelling loudly
  • Think of this as the "Mental Status Exam"
  • Use psychiatric terms here!
  • Example: Endorsing auditory hallucinations, visual hallucinations, responding to internal stimuli, active suicidal ideation, homicidal ideation, thought blocking, paranoid delusions, hopelessness, depressed, etc…
Communication by others
  • Think of this as the "Collateral History"
  • This is information communicated to you by family, police, ER staff, friends, community supports, etc.
  • Document findings from others that suggest risk to self, others, or inability to care for self (e.g. - suicidal behaviour or ideation, violent behaviour or threats, and not caring for self to point of danger)
  • Example: Mother reports patient attempted to hang self last night
  • Think of this as the "Past Psychiatric History"
  • Now can you talk about the condition/diagnosis.
  • What will happen in the future if the patient is not detained?
  • Example: Past diagnosis of schizophrenia, admitted to psychiatric unit in 2010, past history of suicide attempts as documented in chart

Box B Criteria

The Box B Criteria is more complicated in an ER setting and therefore not commonly completed. In order to meet Box B criteria, the patient must have previously received treatment for the same or similar mental disorder in the past, and they must be presenting with symptoms suggestive of that same or similar mental disorder right now. Additionally, they must also have a history of improvement with treatment and evidence that they are likely to improvement with treatment again. Finally, the individual must also have a finding of incapacity and their substitute decision maker (SDM) must also have consented to treatment (i.e. - you have contacted the SDM).

The eligibility threshold for Box B is thus much higher compared to Box A. In Box A, a patient needs to pose a serious and imminent risk to themselves or others. With Box B criteria, you must always do a capacity assessment and have a finding of incapacity (i.e. - also issue a Form 33).

Reasons Fill Box B Instead of Box A

  • Prevents a “revolving door” effect of chronically ill patients going in and out of hospital
  • Decrease the seriousness of deterioration – a patient can be admitted when they start showing early signs and symptoms of illness
  • Prevents patients “falling through the cracks”
  • The moment a patient meets Box B, the are eligible for a Community Treatment Order (CTO)

Tips

Paperwork Tips

The original copy of the Form 1 stays in the patient's chart. If the patient is transferred to another hospital, the Form 1 goes with the patient during the transfer.

Sitters and Passes

On medical/surgical floors, a constant sitter must be ordered because the hospital is legally responsible for keeping the patient in hospital. Patients on a Form 1 are allowed on passes outside if deemed appropriate. They can also be refused passes. This depends on hospital policy, and is not dictated specifically under the Mental Health Act.

What do I do if I Notice The Form 1 is Filled Incorrectly?

There can be implications to filling out a Form 1 incorrectly, including the potential for a $25,000 fine for knowingly contravening the Mental Health Act. Plus, the patient could be considered to be detained “illegally” (thus leading to the potential for civil suit, though this is rare). Therefore, if you notice the Form 1 is filled out incorrectly by another physician, you need to re-do the Form 1 correctly under your name. The maximum time of detention remains 72 hours regardless of when you noticed the error (i.e. - you cannot add another 72 hours at the time you correct the form. You must respect of the spirit of the Form 1!). The technical best practice should be to do the correct Form 1 plus a Form 3 immediately afterwards so a patient is not issued a Form 1 twice.

The Form 1 Only Allows for Detention, Not Treatment

The Form 1 only allows for the physical detention of an individual. It does not allow you to force treatment without a patient's consent. Only emergency treatment is allowed in the event of significant morbidity or mortality. Therefore, if there is no emergency and a patient refuses treatment, you must respect the wishes of the patient even if they are on a Form 1. However, if a patient on a Form 1 is found incapable (i.e. - given a Form 33), and this is not appealed by the patient, you can start involuntary treatment.

The Patient Must Have Physically Been Seen

The physician must have physically seen the patient in order to fill out a Form 1. If, for example, you spoke to the patient over the phone, you cannot fill out a Form 1 (unless you have previously physically seen the patient in the last 7 days).

What if a Patient AWOLs on a Form 1?

  • Only physicians who have seen the patient in the past 7 days can fill out a Form 1 again to request the police apprehend the patient
  • Police must be called and the original Form 1 goes with the police
  • Leave the “For Use at the Psychiatric Facility” section blank
  • If you issue a Form 1 on Wednesday January 1st, the police have until end of Tuesday January 7th 23:59h (that's 7 days) to make the apprehension, not the next Wednesday (that would be 8 days)

Common Errors

Common Form 1 Errors

  • The instructions to complete either Box A OR Box B are in small print. Many MDs overlook this and end up completing both Box A and Box B. Do not do this! Pick Box A (most likely) or Box B, never both!
  • You must make sure you check off the SAME criteria for both the Past/Present and Future Test. (i.e. - do not check off “harm to self” under Past/Present Test, but then check off “harm to others” under the Future Test)
  • Remember the Form 1 has THREE areas where you need to sign
  • Remember the Form 1 has THREE areas where you write the DATE (Jan 1) and the TIME (1000h)

A Form 42 (Notice to Person under Subsection 38.1 of the Act of Application for Psychiatric Assessment under Section 15 or an Order under Section 32 of the Act) is given to a patient to notify them you are detaining them under a Form 1. This must be given to the patient immediately.

When Do You Give The Patient The Form 42?

Two scenarios are possible:
  • Patient in emergency room: MD issues the Form 1 and Form 42 at the same time. Thus, the signing and detention time is also the same
  • Patient in outpatient office: The outpatient MD issues a Form 1, but cannot and does not give the patient the Form 42, because the patient is not yet detained in a Schedule 1 Facility. Only when the patient is at the facility does the receiving MD assess the patient, fill out a Form 42, and issue it to the patient. If you are receiving MD, you write the name of the issuing physician on the Form 42 (NOT your name), but you sign the Form 42 with your signature. Yes, it's that confusing!

Tips

  • The original copy of the Form 42 goes with the patient (this is their legal document)
  • A photocopy of the Form 42 stays in the patient's chart