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 determine Footnote ^*

• [ ] whether the accused is unfit to stand trial

• [ ] whether the accused suffered from a mental disorder so as to exempt the accused from criminal responsibility by virtue of subsection 16(1) of the Criminal Code at the time of the act or omission charged against the accused

• [ ] whether the balance of the mind of the accused was disturbed at the time of commission of the alleged offence, if the accused is a female person charged with an offence arising out of the death of her newly-born child

• [ ] 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, the appropriate disposition to be made in respect of the accused under section 672.54, 672.58 or 672.64 of the Criminal Code or whether the court should, under subsection 672.84(3) of that Act, revoke 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, whether the court should order a stay of proceedings under 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 justice or judge or clerk of the court, as the case may be)