Transfer Evaluation
(To a State Mental Health Treatment Facility)
I, ________________________________________________________________________
concur
do not concur
Full Name of Mental Health Center/Clinic Director or Chief Clinical Officer
that ______________________________________________ , residing at ____________________________________________
Full Name of Person
Name and Address of Receiving Facility
meets statutory criteria for
voluntary
or
involuntary
admission to a state mental health treatment facility.
I find that less restrictive community based treatment alternatives have been considered for this person and were determined to be
inappropriate
unavailable
appropriate and available.
(Check one):
If placement at a State Mental Health Treatment Facility is recommended, specify the reason for the recommendation:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
If it is determined that the person does not meet criteria for admission to a state mental health treatment facility, and consequently a
diversion to a less restrictive voluntary community-based service is appropriate, specify the recommended facility and type of
service:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
____________________________
_____________________________
_______________ ___________ am pm
Signature of Evaluator
Printed Name and Title of Evaluator
Date
Time of Evaluation
______________________________________ ________________________
____________ am
pm
Original Signature of
Date
Time
Executive Director or
Chief Clinical Officer
_______________________________________________________
(______)_____________________
Name and Address of Community Mental Health Center or Clinic
Telephone Number
This form is to be completed by a designated staff member employed by a Community Mental Health Center or Clinic
whenever a person is being considered for admission to a state mental health treatment facility either on a voluntary or
involuntary basis. In the case of potential involuntary admission, the original copy of this form shall be provided for the
Court's consideration prior to the hearing on the petition for involuntary placement. The evaluator or another
knowledgeable person from the center or clinic shall be present at the court hearing to provide testimony as desired by the
court.
cc: Check when applicable and initial/date/time when copy provided:
Individual
Date Copy Provided
Time Copy Provided
Initials of Who
Provided Copy
Circuit Court
am pm
am pm
District DCF Mental Health Office
By Authority of s. 394.455(29), 394.461, Florida Statutes
CF-MH 3089, Feb 05 (obsoletes previous editions) (Mandatory Form)
BAKER ACT