Certificate For Transport To Emergency Receiving Facility (Page 3 of 3) in pdf

Certificate Authorizing Transport to Emergency Receiving Facility and Report of Transportation

(Mental Health) ~ Effective Date: March 31, 2012

PROCEDURES FOR COMPLETION OF FORM “1013”

A. WHO CAN COMPLETE THE FORM 1013?

The Form 1013 can be completed by a licensed Physician, licensed Psychologist, licensed Clinical Social

Worker, or Psychiatric Clinical Nurse Specialist.

B. STEPS PRIOR TO COMPLETION OF THE FORM 1013

1. Determine that the individual does in fact meet criteria of mental illness AND ‘imminent risk’. For more

information re: ADMISSION CRITERIA:

and search for Policy 03-502.

2. Contact the Emergency Receiving Facility (ERF); provide clinical information to the facility and

determine if the facility has the capacity to admit the individual, if admission is necessary.

3. Providing the clinical information will help determine if the individual has signs or symptoms of a

medical condition that would warrant urgent medical intervention prior to transport to the ERF.

Individuals should not be referred to Emergency Rooms for ‘medical clearance,’ but for a specific

complaint that would normally be seen in an emergency department (chest pain, delirium, shortness of

breath). For more information re: MEDICAL CLEARANCE:

and search

for Policy 03-520.

C. STEPS IN COMPLETION OF CERTIFICATE AUTHORIZING TRANSPORT

1. Fill in the County where the Individual is currently located (not the county where the ERF is located).

2. Fill in the name of the patient and the date/time of the evaluation. The evaluation must have been within

48 hours of the signing of the Form 1013.

3. 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 check one or both of the following:

•

‘A’ - if the person 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

•

‘B’ - if the person appears to be so unable to care for his/her own physical health and safety

as to create an imminently life-endangering crisis.

4. 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:

Describe your observations supporting your opinion that the person is mentally ill (i.e. actively

hallucinating, disorganized speech, manic, etc).

5. This Individual: check the appropriate box(es):

[

] 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: (i.e. threatened to cut wrist, threatened to kill relative, etc)

6. Fill in date/time and sign the form to include credentials (M.D., D.O., Ph.D., LCSW, CNP)

7. Complete bottom of form after Emergency Receiving Facility (ERF) agrees to accept patient for

evaluation. This does not have to be done by the signer of the form.

D. STEPS IN COMPLETION OF REPORT OF PEACE OFFICER OR OTHER PERSON PROVIDING

TRANSPORTATION

1. Fill in name of the county where person was transported.

2. Fill in name of person transported.

3. Fill in name of the Emergency Receiving Facility (ERF) where the person was taken.

4. Complete the ‘time/date’ of pick up, location and observations during transit.

5. Fill in name/address of family or others who were present when the individual was taken into custody (if

applicable - law enforcement only).

6. Fill in Comments or information from family or others who have personal knowledge of individual (if

applicable).

7. Indicate if physical restraints were used in transit and the reasons for the restraints.

8. Comment of the person’s obvious physical condition (apparent injuries, distress).

9. Other information: complete if applicable.

10. Indicate who provided the transportation.

11. Sign/date form and give to Emergency Receiving Facility.

Last Revised by DBHDD – 03.20.2012

Certificate For Transport To Emergency Receiving Facility Page 3

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