Certificate Of Professional Initiating Involuntary Examination Form printable pdf download

Certificate of Professional Initiating Involuntary Examination

All sections of this form must be completed and legible (please print)

I have personally examined (printed name of person) _____________________________________________ at time _________ am pm (time must be

within the preceding 48 hours) on _________/ ________/ 20 ______ in ________________________________ County and that person appears to

meet criteria for involuntary examination OR I am a physician who has determined that (printed name of person) _______________________________

has failed or has refused to comply with the treatment ordered by the court, and, in my clinical judgment, efforts were made to solicit compliance and the

person appears to meet the criteria for involuntary examination. Section IV of this form is completed to document the requirements of the law.

This is to certify that my professional license number is:

and I am a (check one box)

Psychiatrist

Physician (non-psychiatric)

Clinical Psychologist

Psychiatric Nurse

Clinical Social Worker

Mental Health Counselor

Marriage and Family Therapist

Each as defined in s.394.455, F.S.

Section I: CRITERIA

There is reason to believe person has a mental illness as defined in Section 394.455(18), Florida Statutes (excludes retardation or developmental

disabilities, intoxication, or conditions manifested only by antisocial behavior or substance abuse impairment).

Diagnosis of

DSM Code(s)

Mental Illness is:

(if known)

List all mental

health diagnoses

applicable to this

person

AND BECAUSE OF MENTAL ILLNESS

Person has refused voluntary examination after

Person is unable to determine for

Statute requires that at

conscientious explanation of disclosure of the purpose

himself/herself whether examination is

least one be checked,

of examination

necessary

but both may be

checked if both apply

Without care and treatment the person is likely to suffer

AND EITHER

There is substantial likelihood that without care

from neglect or refuse to care for himself/herself, and

or treatment the person will cause serious bodily

(A and/or B)

such neglect or refusal poses a real and present threat

harm to (check one or both):

of substantial harm to his or her well-being and it is not

self

others

apparent that such harm may be avoided through the

help of willing family members or friends or the provision

in the near future, as evidenced by recent

of other services

behaviors (describe behaviors at top of page 2)

Section II: SUPPORTING EVIDENCE

A. My observations supporting these criteria including the person’s behaviors and statements, specifically those related to suicidal ideation, previous

suicide attempts, homicidal ideation or self-injury are as follows:

CONTINUED OVER

Certificate Of Professional Initiating Involuntary Examination Form

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