Criminal Code (R.S.C., 1985, c. C-46)

Canada,

Province of

(territorial division)

Whereas I have reasonable grounds to believe that evidence of the mental condition of (name of accused), who has been charged with , may be necessary to Footnote ^*

• [ ] if a verdict of unfit to stand trial or a verdict of not criminally responsible on account of mental disorder has been rendered in respect of the accused, make a disposition under section 672.54 of the Criminal Code or determine whether the Review Board should, under subsection 672.84(1) of that Act, refer to the superior court of criminal jurisdiction for review a finding that the accused is a high-risk accused

• [ ] if a verdict of unfit to stand trial has been rendered in respect of the accused, determine whether the Review Board should make a recommendation to the court that has jurisdiction in respect of the offence charged against the accused to hold an inquiry to determine whether a stay of proceedings should be ordered in accordance with section 672.851 of the Criminal Code

I hereby order an assessment of the mental condition of (name of accused) to be conducted by/at (name of person or service by whom or place where assessment is to be made) for a period of days.

This order is to be in force for a total of days, including travelling time, during which time the accused is to remain Footnote ^*

• [ ] in custody at (place where accused is to be detained)

• [ ] out of custody, on the following conditions:

(set out conditions, if applicable)

• Return to footnote ^*Check applicable option.

Dated this day of A.D. , at  .

(Signature of Chairperson of the Review Board)