Notice Of Return Of Escapee Or Conditional Releasee {DMH 5-83-01}

STATE OF NORTH CAROLINA NOTICE OF RETURN OF ESCAPEE OR CONDITIONAL RELEASE Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Date: ________________ Re: Date of UA: ________________ Facility: __________________________ Address:__________________________ ___________________________ Unit/Bldg: ________________ _____________________________________________ (Patient) Last known address: _________________________________ Medical Record Number: _____________________________ This is to notify you that the above named patient was returned to the above named facility on _________ at _________ following his/her ESCAPE BREACH OF CONDITIONAL RELEASE. (date) (time) Patient returned via: self police _____________________ (specify agency) family other ______________ (specify) Location of patient when found: _________________________________________________________________ Incident(s) that occurred to patient during elopement None/unknown Suicide attempt Assault Other Drug/Alcohol use Rape Self-injurious behavior Suicide Severity of injury/damage to patient No treatment/injury Unknown Minor first aide Medical intervention required Hospitalization required Death No property damage Minimal property damage Substantial property damage Incident(s) committed by patient during elopement Assault Other Homicide Rape Theft Breaking & Entering None/Unknown Severity of injury/damage to victim (other than patient) No treatment/injury Unknown Minor first aide Medical intervention required Hospitalization required Death No property damage Minimal property damage Substantial property damage Signature and Title of Responsible Professional DISTRIBUTION: Any law enforcement office notified HIM Initial examiner if involuntarily committed Area program (if appropriate) Form No. DMH 5-83-01 Revised September 2001 Risk management coordinator Official placing patient on detainer Next of kin/legally responsible party Clerk of Superior Court in county of commitment NOTICE OF RETURN OF ESCAPEE OR CONDITIONAL RELEASE American LegalNet, Inc. www.USCourtForms.com