Criminal Code

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

• [ ] 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)