Certificate For Transport To Emergency Receiving Facility

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Georgia Department of Behavioral Health
& Developmental Disabilities (DBHDD)
FORM 1013 – CERTIFICATE AUTHORIZING
TRANSPORT TO EMERGENCY RECEIVING FACILITY &
REPORT of TRANSPORTATION (Mental Health)
Identification
STATE OF GEORGIA, COUNTY OF___________________________
DATE ________________
This is to certify that I have personally examined _________________________________________________
on _________________________, 20____
at ______m, which was within the preceding 48 hours of the signing of
this certificate.
In my opinion this Individual appears to be a mentally ill person requiring involuntary treatment in that he/she appears
to be mentally ill AND:
[ ] A. presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent
expressed threats of violence which present a probability of physical injury to self or to other persons; OR
[ ] B. appears to be so unable to care for his/her own physical health and safety as to create an imminently life-
endangering crisis.
At the time of my evaluation, the conditions checked below were present:
[
] This Individual appears to be mentally ill. My opinion is based on the following observations:
_____________________________________________________________________________________
This Individual:
[
] Has committed/expressed recent overt acts/threats towards others.
[
] Has committed/expressed recent acts/threats of violence to self.
[
] Presents an imminently life endangering crisis to self because he/she is unable to care for his/her own
health and safety.
For example: __________________________________________________________________________
As soon as possible, but within 72 hours after receiving this certificate, the Peace Officer shall make diligent efforts to
take the above-named Individual into custody. Thereafter, the Peace Officer shall transport the above-named
Individual to the emergency receiving facility serving the county where such person is found, as named above. This
certificate expires 7 days after it is executed. This certificate and the Report of Peace Officer are to be delivered by the
Peace Officer to the emergency receiving facility and are to be made a part of the above-named Individual's clinical
record.
If private transportation by family, friends, or other means is deemed safe, it shall be encouraged and authorized.
This does not relieve the county governing authority from its responsibility to arrange for transportation when needed
or requested.
____________________________________________________________________________________________
SIGNATURE AND PRINTED NAME of Licensed Physician, Licensed Psychologist, Licensed Clinical Social Worker
or Clinical Nurse Specialist in Psychiatric/Mental Health
___________________________________________________
Date___________ 20____ Time ___________m
Telephone Number
**************************************************************************************************************************************
I ________________(staff at referring facility) have communicated with ______________________(staff at receiving
facility) at _________________(name of receiving facility), ______________ (telephone number), who stated that the
facility has a bed available for this individual. This certificate authorizes the peace officer or other person to deliver the
individual named on this 1013 to the named facility for examination to determine whether admission is necessary.
____________________________________________________________________________________________
SIGNATURE AND PRINTED NAME of staff at Referring Facility
Date_______ 20____ Time ________m
For Receiving Facility Staff Use Only – A copy of form 1013 is placed in the clinical record.
Signature of Staff
Title
Date
___________________________________________________________________________________________________
Form 1013 – Certificate Authorizing Transport to Emergency Receiving Facility & Report of Transportation – Mental Health
DBHDD By Authority of O.C.G.A. § 37-3-41, 37-3-42 & 37-3-101 -Form Last Revised 03.20.2012; Effective 03.31.2012- Page 1 of 2

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