Dsamh Form 43-2 Order Of Placement Into A More Restrictive Environment printable pdf download

Dsamh Form 43-2 Order Of Placement Into A More Restrictive Environment

ORDER OF PLACEMENT INTO A MORE RESTRICTIVE ENVIRONMENT

_____________________________________

Local Mental Health Authority

TO:

_________________________

Case No._________________

Patient

Having been previously committed to _______________________________,

Local Mental Health Authority

on __________________________, by order of the ________________ District

Date of Commitment

Court and having been placed in a less restrictive environment is aggravating your

mental illness or that you have failed to comply with the specified treatment plan to

which you have agreed in writing as follows:________________

__________________________________________________________________

Pursuant to Utah Code Annotated 62A-15-637(2) (2002), you are hereby

ordered to ___________________________________ immediately. You or your

Local Mental Health Authority

legal representative, to which you are entitled, may request a hearing of the change.

Dated this ____ day of ____________, 20_______. ________________________

Director or Designee

ENDORSEMENT FOR CUSTODY AND TRANSPORTATION

I, the undersigned, hereby request a mental health officer or peace officer to

immediately take __________________________ into custody and transport said

Proposed Patient

proposed patient to the local mental health authority or to a temporary emergency

facility to be detained in accordance with the above order.

Dated this _____ day of __________________, 20_________

________________________

Director or Designee

DSAMH Form 43-2, Revised 2014

Utah Code Annotated 62A-15-637(2)(2002)

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Dsamh Form 43-2 Order Of Placement Into A More Restrictive Environment