Form Mh 302 Ncr - Application For Assessment And Evaluation printable pdf download

Los Angeles County Department of Mental Health – MH 302 NCR

(7/16/14)

DETAINMENT ADVISEMENT

APPLICATION FOR ASSESSMENT, EVALUATION, AND CRISIS

INTERVENTION OR PLACEMENT FOR EVALUATION AND

My name is ____________________________________________

TREATMENT

I am a (Peace Officer, etc.) with (Name of Agency). You are not

Confidential Client/Patient Information

under criminal arrest, but I am taking you for examination by mental

health professionals at (Name of Facility) ____________________.

See California Welfare and Institutions Code (W & I ) Code, Section 5328 & HIPAA

Privacy Rule 45 C.F.R. § 164.508

You will be told your rights by the mental health staff.

Welfare and Institutions Code (W&C Code), Section 5150(f) and (g), requires that

each person, when first detained for psychiatric evaluation, be given certain specific

If taken into custody at his or her residence, the person shall also

information orally and a record be kept of the advisement by the evaluating facility.

be told the following information

Advisement Complete

Advisement Incomplete

You may bring a few personal items with you, which I will have to

approve. Please inform me if you need assistance turning off any

Good Cause For Incomplete Advisement

appliance or water. You can make a phone call and leave a note to

tell your friends or family where you have been taken.

Advisement Completed By

Position

Language or Modality Used

Date of Advisement

To (name of 5150 designated facility) ___________________________________________________________________________________

Application is hereby made for the assessment and evaluation of _____________________________________________________________

Residing at _________________________________________________________________, California, for up to 72-hour assessment,

evaluation, and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to Section 5150 et seq. (adult) or

Section 5585 et seq. (minor), of the W&I Code. If a minor, authorization for voluntary treatment is not available and to the best of my knowledge,

the legally responsible party appears to be/is: (Circle one) Parent; Legal Guardian; Juvenile Court under W&I Code 300; Juvenile Court under

W&I Code 601/602; Conservator. If known, provide names, address and telephone number: ________________________________________

__________________________________________________________________________________________________________________

The above person’s condition was called to my attention under the following circumstances: ________________________________________

__________________________________________________________________________________________________________________

I have probable cause to believe that the person is, as a result of a mental health disorder, a danger to others, or to himself/herself, or gravely

disabled because (state specific facts) __________________________________________________________________________________

__________________________________________________________________________________________________________________

Based upon the above information, there is probable cause to believe that said person is, as a result of mental disorder:

A danger to himself/herself.

A danger to others.

Gravely disabled adult.

Gravely disabled minor.

Minors only:

Based upon the above information, it appears that there is probable cause to believe that authorization for voluntary treatment

is not available.

Signature, title, and badge number of peace officer, professional person in charge or the facility designated by

Date:

Phone:

the county for evaluation and treatment, member of the attending staff, designated members of a mobile crisis

team, or professional person designated by the county.

Time:

For patients in medical

Name of Law Enforcement Agency or Evaluation Facility/Person

Address of Law Enforcement Agency or Evaluation

ER’s, detention began:

Facility/Person

Date:

Time:

NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY

Notify (officer/unit & telephone #)

________________________________________________________________________________________________________

NOTIFICATION OF PERSON’S RELEASE IS REQUESTED BY THE REFERRING PEACE OFFICER BECAUSE:

The person has been referred to the facility under circumstances which, based upon an allegation of facts regarding actions witnessed by

the officer or another person, would support the filing of a criminal complaint.

Weapon was confiscated pursuant to Section 8102 W&I Code. Upon release, facility is required to provide notice to the person regarding the procedure to

obtain return of any confiscated firearm pursuant to Section 8102 W&I Code.

SEE REVERSE SIDE REFERENCES AND DEFINITIONS

Original: Accompany Client to Assessment, Evaluation, and Crisis Intervention Location or 5150/5585 Designated Facility

Copy: 5150/5585 Initiator

Reference: DHCS 1801 (04/2014)

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Form Mh 302 Ncr - Application For Assessment And Evaluation

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