This form is used to authorize Selkirk Mental Health Centre staff to place the patient in seclusion under the following circumstances: the patient is in danger of harming themselves or others, having troubles settling for the night, after receiving calming medication, or needing less stimulus to calm themselves. This form is available to Selkirk Mental Health Centre patients and treatment team staff members. This form is enforced by Selkirk Mental Health Centre and The Mental Health Act c.110 of Manitoba.