Dsamh Form 36-1 Application For Order Of Involuntary Commitment (Page 2 of 2) in pdf

Names and addresses of those to be notified:

Parent(s) or Legal Guardian:____________________________________________

__________________________________________________________________

Address

Phone

Adult Family Member(s)_______________________________________________

Relationship to proposed patient

__________________________________________________________________

Address

Phone

Legal Counsel_______________________________________________________

__________________________________________________________________

Address

Phone

Other Person(s)______________________________________________________

Relationship to proposed Patient

__________________________________________________________________

Address

Phone

CERTIFICATE

Upon the application of _________________________, I, _____________________,

Affiant

a duly licensed physician in the State of Utah, a medical officer of the United States

Government in the performance of my official duties, or a designated examiner duly

appointed by the Division of Substance Abuse and Mental Health pursuant to UCA 62A-15-

602

), examined: _

_, on the____ day of ________, 20____,

(2002

Proposed Patient

which is within a seven day period immediately preceding this certificate, and certify that in

my opinion the said proposed patient is mentally ill and should be involuntarily committed to

___

_____.

Local Mental Health Authority

Dated this ____ day of _______________, 20_____.

__________________________

Signature

__________________________

Title

__________________________

Address

Instructions: “Proceedings for involuntary commitment of an individual who is 18 years of age or older may be commenced by

filing a written application with the district court of the county in which the proposed patient resides or is found, by a

responsible person who has reason to know of the condition of the proposed patient which lead to the belief that the individual

is mentally ill and should be involuntarily committed. That application shall be accompanied by: (a) a certificate of a licensed

physician or a designated examiner stating that within a seven-day period immediately preceding the certification the

physician or designated examiner has examined the individual, and that he is of the opinion that the individual is mentally ill

and should be involuntarily committed; or (b) a written statement by the applicant that the individual has been requested to

but has refused to submit to an examination of mental condition by a licensed physician or designated examiner. The

application shall be sworn to under oath and shall state the facts upon which the application is based.” UCA 62A-15-631(1)

(2002)

DSAMH Form 36-1, Revised 2013

Utah Code Annotated 62A-15-631(a)(b) (2003)

(Page 2 of 2)

Dsamh Form 36-1 Application For Order Of Involuntary Commitment Page 2

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