Government of Ontario: Ministry of Health
Withdrawal of Application to Review Board under the Mental Health Act
To: Chair of the Review Board
Re: (print full name of patient)
Casebook no
name of psychiatric facility
Application to the Review Board to review:
involuntary admission (Form 16)
competence to consent to treatment (Form 32)
competence to examine my clinical record (Form 31)
competence to manage my estate (Form 18)
observation, care and treatment of an informal patient (Form 25)
(date of application, if known)
This is to advise you that I wish to withdraw my application to the Review Board.
Witness
Signature of applicant
Date : (day / month / year)
1472–41 (99/06)*
7530–4760