Baker Act Service Eligibility Form - Florida
ADVERTISEMENT
1Baker Act Service Eligibility
Public Receiving Facility Name: ___________________________________________________________________
1. IDENTIFYING INFORMATION:
Person’s Name: _______________________________
Date of Birth: __________________________________Gender:
Male
Female
Race: ______________
2. FINANCIAL INFORMATION:
Prospective monthly income (6-month average) $__________________
Number of Family Members: _________________
Title XX Eligible:
Yes
No
3. LEGAL STATUS:
Voluntary Admission
Involuntary Examination
4. CRITERIA: (check the appropriate criteria)
There is reason to believe the above-named person has a mental illness, as defined in 394.455(18), AND
Without care or treatment, the person is likely to suffer from neglect or refuse to care for himself or herself, such
neglect or refusal poses a real and present threat of substantial harm to his or her well-being, and it is not
apparent that such harm may be avoided through the help of willing family members or friends or the provision of
other services,
OR
There is a substantial likelihood that without care or treatment the person will cause serious bodily harm to himself
or herself or others in the near future, as evidenced by recent behavior.
5. MOST RECENT DSM OR ICD ADMISSION DIAGNOSIS AND CODE NUMBER: ___________________________
6. SUMMARY: Behavioral manifestations justifying diagnosis. (A completed CF-MH 3052a or 3052b or Ex Parte Order
may be attached for persons on involuntary status)
7. RECOMMENDED DISPOSITION / PLACEMENT:
8. WHY IS A LESS RESTRICTIVE PLACEMENT NOT BEING UTILIZED?
9. APPROVAL OF DISPOSITION/PLACEMENT
does
does not
include authorization for payment of
contracted 24-hour care.
______________________________________________________
_________________
__________ am pm
Signature of Administrator or Designee
Date
Time
________________________________________________________
Printed Name of Administrator or Designee
By authority of s. 394.74, 394.875, 394.879, Florida Statutes
CF-MH 3084, Feb 05 (obsoletes previous editions)
(Mandatory Form for Public Receiving Facilities)
BAKER ACT
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal