Request For Release From Admission To Form printable pdf download

Request For Release From Admission To Form

REQUEST FOR RELEASE FROM ADMISSION TO

____________________________________

Local Mental Health Authority

Patient Name: _____________________________

TO THE DIRECTOR:

I, ____________________, on this _____ day of _______________, 20____,

do hereby request the release of ________________________________, a

voluntary patient of the Local Mental Health Authority.

_________________________________

Signature of Patient, Legal Guardian, Parent, Spouse, or

Next of Kin*

Received by _______________________, this ____ day of ____________, 20____,

Local Mental Health Authority Representative

at the hour of ________________ a.m./p.m.

_____________________________

Signature of Staff Member

Received by _________________, this _____, day of ________________, 20____,

at the hour of _________ a.m./p.m.

_____________________________

Signature of Clinical Director of Designee

Instructions: A voluntary patient who requests release, or whose release is requested in writing by his legal guardian, parent,

spouse, or adult next of kin, shall be immediately released except that: (1) if the patient was voluntarily admitted on his own

application, and the request for release is made by a person other than the patient, release may be conditioned upon

agreement of the patient; and (2) if a local mental health authority, or its designee is of the opinion that release of a patient

would be unsafe for that patient or others, release of that patient may be postponed for up to 48 hours, excluding weekends

and holidays, provided that the local mental health authority, or its designee, shall cause to be instituted involuntary

commitment proceedings with the district court within the specified time period, unless cause no longer exists for instituting

those proceedings. Written notice of that postponement with the reasons shall be given to the patient without undue delay.

No judicial proceedings may be commenced with respect to a voluntary patient unless he has requested release. UCA 62A-15-

627 (2002)

DSAMH Form 31-1, Revised 2012

Utah Code Annotated 62A-15-627 (2002)

Request For Release From Admission To Form