Certification And Report On Petition For Judicial Admission {PCM 215a}

en-USIn the matter of en-USFirst, middle, and last nameen-USOn en-USDateen-US , I examined the individual and report that: 1. þ The individual þ does þ does not þ meet the criteria for treatment. 2. þ My diagnosis is that the individual þ does þ does not þ have an intellectual disability. 3. þ The individual þ a. þ can þ cannot þ be reasonably expected within the near future to intentionally or unintentionally þ seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. þ en-US b. has been arrested and charged with an offense that was a result of the intellectual disability. þ I base my conclusion on the following facts: en-US þ en-US þ 4. þ The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending þ hearing. en-USDate þ en-USSignature þ en-USName and titleen-USOn en-USDateen-US , I examined the individual and report that: 1. þ The individual þ does þ does not þ meet the criteria for treatment. 2. þ My diagnosis is that the individual þ does þ does not þ have an intellectual disability. 3. þ The individual þ a. þ can þ cannot þ be reasonably expected within the near future to intentionally or unintentionally þ seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. þ en-US b. has been arrested and charged with an offense that was a result of the intellectual disability. þ I base my conclusion on the following facts: en-US þ en-US þ 4. þ The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending þ hearing. en-USDate þ en-USSignature þ en-USName and titleen-USCERTIFICATION OF EXAMINERS American LegalNet, Inc. www.FormsWorkFlow.com File No. 1. þ I, en-USNameen-US , as en-USProfession, organization, and titleen-US , þ have met with and evaluated the individual and report that his/her mental, physical, social, and educational condition is: þ en-US þ en-US þ en-US 2. þ The following is a list of available forms of care and treatment that may serve as an alternative to admission to a facility. þ a. þ Residential placement: en-US þ Availability (specify): en-US þ b. þ Day activity programs: en-US þ en-US þ Availability (specify): en-US þ c. þ Outpatient treatment: en-US þ en-US þ Availability (specify): en-US þ d. þ Custody of friend or relative: en-US þ Availability (specify): en-US þ e. þ Home care or homemaker services: en-US þ Availability (specify): en-US þ f. þ Inpatient treatment at private psychiatric hospital: en-US Name of hospital þ Availability (specify): en-US þ g. þ Other: en-US þ Availability (specify): en-US 3. þ I recommend the most appropriate living arrangement for the individual in terms of type and location and the availability of þ support services to be en-US en-US .en-USI declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best ofen-USmy information, knowledge, and belief. en-USDate þ en-USAddress en-USSignature þ en-USCity, state, zip Telephone no.en-USREPORT ON PETITION FOR JUDICIAL ADMISSION American LegalNet, Inc. www.FormsWorkFlow.com