Emergency Certificate Supplement {DMH 5-72-01-B}

STATE OF NORTH CAROLINA Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services County _____________________ Client Record # ______________ File # __________________ EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT AGE BIRTHDATE Film # __________________ SEX County Phone RACE M.S. NAME OF RESPONDENT: ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in facility) LEGALLY RESPONSIBLE PERSON NEXT OF KIN (Name and address) Relationship Phone PETITIONER (Name and address) Relationship Phone The above-named respondent was examined on __________________, 20___ at ____________ o'clock ____.M. at ______________ __________________________________________________. Included in the examination was an assessment of the respondent's: (1) current and previous mental illness or mental retardation including, if available, previous treatment history; (2) dangerousness to self or others as defined in G.S. 122C-3 (11*); (3) ability to survive safely without inpatient commitment, including the availability of supervision from family, friends, or others; and (4) capacity to make an informed decision concerning treatment. (1) current and previous substance abuse including, if available, previous treatment history; and (2) dangerousness to himself or others as defined in G.S. 122C-3 (11*). The following findings and recommendations are made based on this examination. *See Statutory Definitions on Reverse Side. SECTION I - CRITERIA FOR COMMITMENT Inpatient. It is my opinion that the respondent is: mentally ill; dangerous to self; dangerous to others (1st Exam - Physician or Psychologist) In addition to being mentally ill is also mentally retarded (2nd Exam - Physician only) none of the above Outpatient. It is my opinion that: (Physician or Psychologist) order to prevent further disability or deterioration which would predictably result in dangerousness as defined by G.S. 122C-3 (11*) the respondent's current mental status or the nature of his illness limits or negates his/her ability to make an informed decision to seek treatment voluntarily or comply with recommended treatment none of the above Substance Abuse. It is my opinion that the respondent is: (1st Exam -Physician or Psychologist; 2nd Exam - If 1st exam done by Physician, 2nd exam may be done by Qual. Prof.) a substance abuser dangerous to himself or others none of the above the respondent is mentally ill the respondent is capable of surviving safely in the community with available supervision based upon the respondent's treatment history, the respondent is in need of treatment in SECTION II - DESCRIPTION OF FINDINGS Clear description of findings (findings for each criterion checked above in Section I must be described): Form No. DMH 572-01 Revised September 2001 EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY COMMITMENT American LegalNet, Inc. www.USCourtForms.com STATE OF NORTH CAROLINA Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services (over) Form No. DMH 572-01 Revised September 2001 EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY COMMITMENT American LegalNet, Inc. www.USCourtForms.com Notable Physical Conditions: Current Medications (medical and psychiatric) Impression/Diagnosis: SECTION III - RECOMMENDATION FOR DISPOSITION Inpatient Commitment for _________ days (respondent must be mentally ill and dangerous to self or others) Outpatient Commitment (respondent must meet ALL of the first four criteria outlined in Section I, Outpatient) Proposed Outpatient Treatment Center or Physician: (Name)___________________________________________________ (Address and Phone Number) __________________________________________________________________________ __________________________________________________________________________ Substance Abuse Commitment (respondent must meet both criteria outlined in Section I, Substance Abuse) Release respondent pending hearing - Referred to:________________________________________________________ Hold respondent at 24-hour facility pending hearing - Facility ________________________________________________ Respondent does not meet the criteria for commitment but custody order states that the respondent was charged with a violent crime, including a crime involving assault with a deadly weapon, and that he was found not guilty by reason of insanity or incapable of proceeding: therefore, the respondent will not be released until so ordered following the court hearing. Respondent or Legally Responsible Person Consented to Voluntary Treatment Release Respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria) Other (Specify) ___________________________________________________________________________________________ ________________________________________________ M.D. Physician Signature __________________________________________________ __ Signature/Title - Eligible Psychologist/Qualified Professional __________________________________________________ __ Print Name of Examiner This is to certify that this is a true and exact copy of the Examination and Recommendation for Involuntary Commitment __________________________________________________ __ Original Signature - Record Custodian __________________________________________________ __ Title __________________________________________________ __ Address or Facility __________________________________________________ __ Date NOTE: Only copies to be introduced as evidence need to be certified. Address or Facility City and State () or () Telephone Number Original: Medical Record CC: Clerk of Superior Court where petition was initiated (initial hearing only) Clerk of Superior Court where 24-hour facility is located or where outpatient treatment is supervised Respondent and State's Attorneys, when applicable Proposed Outpatient Treatment Center or Physician (Outpatient Commitment/Area Program or Physician (Substance Abuse Commitment) NOTE: If it cannot be reasonably anticipated that the clerk will receive the copies within 48 hours of the time that it was signed, the physician or eligible psychologist/qualified professional shall communicate his findings to the clerk by telephone. *STATUTORY DEFINITIONS "Dangerous to himself". Within the recent past: (a) the individual has acted in such a way as to show: (1