Dmh-0025 - Application For Emergency Admission Form printable pdf download

Ohio Department of Mental Health

Application for Emergency Admission

In Accordance with Sections 5122.01 and 5122.10 ORC

DMH-0025

TO: The Chief Clinical Officer of __________________________________________________

_________________________

(Regional Psychiatric Hospital - RPH/Facility Name)

(Date/Time)

The undersigned has reason to believe that: ____________________________________

(Name of Person to be Admitted)

Is a mentally ill person subject to hospitalization by court order under division B Section 5122.01 of the Revised Code, i.e.,

this person

(1) Represents a substantial risk of physical harm to self as manifested by evidence of threats of, or attempts

at, suicide or serious self-inflicted bodily harm;

(2) Represents a substantial risk of physical harm to others as manifested by evidence of recent homicidal or

other violent behavior, evidence of recent threats that place another in reasonable fear of violent behavior

and serious physical harm, or other evidence of present dangerousness;

(3) Represents a substantial and immediate risk of serious physical impairment or injury to self as manifested by

evidence that the person is unable to provide for and is not providing for the person's basic physical needs

because of the person's mental illness and that appropriate provision for those needs cannot be made

immediately available in the community; or

(4) Would benefit from treatment in a hospital for his mental illness and is in need of such treatment as

manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or

himself.

Represents a substantial risk of physical harm to self or others if allowed to remain at liberty pending examination.

Therefore, it is requested that said person be admitted to the above named facility.

STATEMENT OF BELIEF

Must be filled out by one of the following: a psychiatrist, licensed clinical psychologist, licensed physician, health or police officer, sheriff

or deputy sheriff.

(Statement shall include the circumstances under which the individual was taken into custody and the reason for the person's belief that

hospitalization is necessary. The statement shall also include a reference to efforts made to secure the individual's property at his

residence if he was taken into custody there. Every reasonable and appropriate effort should be made to take this person into custody in

the least conspicuous manner possible.)

Original - Medical Record, Copy - Suspense File

APPLICATION FOR EMERGENCY ADMISSION

Page 1 of 2

DMH-0025 (Rev. 01/11)

DMH-MedR-1030

Dmh-0025 - Application For Emergency Admission Form