Notice Of Certification Of Up To 30 Days Of Additional Intensive Treatment Form - County Of San Diego, Health And Human Services Agency
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1County of San Diego, Health and Human Services Agency
Behavioral Health Services
NOTICE OF CERTIFICATION OF UP TO 30 DAYS OF ADDITIONAL INTENSIVE TREATMENT
(Rev. 06/14)
Confidential Patient Information
HIPAA Privacy Rule
See Welfare & Institutions Code
45 C.F.R. § 164.508
Section 5328 and Penal Code 11142
The authorized agency providing evaluation services in the County of ________________________ has evaluated the condition of:
Name ____________________________________________________________________________________________________
Address ____________________________________________________________________________________________________
Marital Status ______________________
Date of Birth ______________________________________ Sex
_______________
We, the undersigned, allege that the above-named person is, as a result of a mental disorder or impairment by chronic alcoholism:
Gravely disabled as defined in paragraph (1) of subdivision (h) or subdivision (1) of Section 5008 of the Welfare & Institutions Code
The specific facts which form the basis for our opinion that the above-named person meets the classification indicated above are as
follows:
The above-named person has been informed of this evaluation, and has been advised of the need for, but has not been able or willing to
accept treatment on a voluntary basis, or to accept referral to, the following services:
We, therefore, certify the above-named person to receive intensive treatment related to the mental disorder or impairment by chronic
alcoholism beginning this _____________________ day of __________________, 20_____ (date 30-day hold begins), in the intensive
treatment facility herein named
______________________________
Date of Assessment
Signature ___________________________________________________________________________________________________
Signature ___________________________________________________________________________________________________
I hereby state that I delivered a copy of this notice this day to the above-named person and that I informed him or her that unless
judicial review is requested, a certification review hearing will be held within four days of the date on which the person is certified for
a period of intensive treatment and that an attorney or advocate will visit him or her to provide assistance in preparing for the hearing
or to answer questions regarding his or her commitment or to provide other assistance. The court has been notified of this certification
on this day.
Patient Requests Writ
Patient Does Not Request Writ
Signature ____________________________________________________________________________________________________
Copies:
Person Certified - Personally delivered
Superior Court, Counselor in Mental Health
Public Defender, if any
Person's Attorney
County Counsel
Patient Advocate
Facility Providing Intensive Treatment
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