4919-57 (2014/02) © Queen's Printer for Ontario, 2014 Disponible en français

Ministry of Health and Long-Term Care

Psychiatric Patient Advocate Office (PPAO) Tel: 1 866 851-1212 416 327-8240 (Toronto)

Request for Rights Advice Community Treatment Order(CTO)

Instructions1. All addresses must be complete, including Postal Codes.2. Please ensure that each person to receive rights advice has Form 49 and Plan. If sent by mail please note date.3. Fax the completed request with Form 49 and Community Treatment Plan to the PPAO Intake Office at 1 866 822-2333 or 416 314-4484 (Toronto).

For Inpatients:– Place this request form in the PPAO binder, with Form 49 and Community Treatment Plan attached. – Original Form 50 is left on the inpatient unit. Rights Adviser will fax Form 50 if requested.

Date (yyyy/mm/dd)

Section 1 - Requestor Contact InformationFirst Name Last Name Name of Facility

Unit Number Street Number Street Name City/Town

Province Postal Code Telephone Numberext.

Fax Number

Section 2 - Individual(s) to Receive Rights AdvicePatient First Name Patient Last Name Communication Needs

Inpatient

Outpatient

Name of Facility Room Number Telephone Number

Home Address

Method of ContactPhone Other (specify)

Capable Incapable 1st Issue Renewal Number Previous CTO expiry date (yyyy/mm/dd)

Re-Issue (specify reasons)

Note:Substitute Decision Maker 1First Name Last Name Communication Needs

City/Town Province Telephone Number 1 Telephone Number 2 Telephone Number 3ext.

Note:

Substitute Decision Maker 2First Name Last Name Communication Needs

City/Town Province Telephone Number 1 Telephone Number 2 Telephone Number 3ext.

Note:

Section 3 - Submission of Form 50 Confirmation of Rights AdviceFax to: Requestor Other (specify)

Mail Original to: Requestor Not Required Other (specify)

Note:

For PPAO Office Use OnlyIntake

Date Time

R A Name

Assigned Date Time

This telecopy contains confidential information intended only for the Psychiatric Patient Advocate Office. Any other distribution, copying or disclosure is strictly prohibited. If you have received this telecopy in error, please notify our office immediately by telephone at 1 866 851-1212.