Request for Rights Advice Community Treatment Order (CTO)

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Ministry of Health
and Long-Term Care
Psychiatric Patient
Advocate Office (PPAO)
Tel: 1 866 851-1212
416 327-8240 (Toronto)
Print Form
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Request for Rights Advice
Community Treatment Order
(CTO)
Instructions
1. 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 Information
First Name
Unit Number
Last Name
Street Number
Province
Name of Facility
Street Name
City/Town
Postal Code
Telephone Number
Fax Number
ext.
Section 2 - Individual(s) to Receive Rights Advice
Patient First Name
Inpatient
Outpatient
Patient Last Name
Name of Facility
Room Number
Telephone Number
Home Address
Method of Contact
Phone
Capable
Communication Needs
Incapable
Other (specify)
1st Issue
Renewal Number
Previous CTO expiry date (yyyy/mm/dd)
Re-Issue (specify reasons)
Note:
Substitute Decision Maker 1
First Name
Last Name
City/Town
Province
Communication Needs
Telephone Number 1
Telephone Number 2
Telephone Number 3
ext.
Note:
Substitute Decision Maker 2
First Name
Last Name
City/Town
Province
Communication Needs
Telephone Number 1
Telephone Number 2
Telephone Number 3
ext.
Note:
Section 3 - Submission of Form 50 Confirmation of Rights Advice
Fax to:
Requestor
Mail Original to:
Requestor
Other (specify)
Not Required
Other (specify)
Note:
For PPAO Office Use Only
Intake
RA
Assigned
Date
Time
Name
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.
4919-57E (2014/03)
© Queen's Printer for Ontario, 2014
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