Form 1001-B - Application For Voluntary Admission Pursuant To Section 37.2-814
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1Commonwealth of Virginia
DBHDS 1001B
Va. Code § 37.2-814
7/2009
DEPARTMENT OF BEHAVIORAL HEALTH AND DEVELOPMENTAL SERVICES
APPLICATION FOR VOLUNTARY ADMISSION
TO A HOSPITAL OR OTHER FACILITY IN VIRGINIA
PURSUANT TO SECTION 37.2-814, CODE OF VIRGINIA (1950), AS AMENDED
TO: The Director __________________________________________________________________________
(Insert name of Hospital or Other Facility)
I, _________________________________________, hereby apply for admission as a voluntary patient for care
(Name of applicant)
and treatment and I agree to hospitalization and treatment in the aforementioned facility for 72 hours, unless
sooner discharged by the director. Furthermore, I agree to give the facility 48 hours notice of my desire to leave
and to remain in the facility during this notice period unless sooner discharged by the director.
I understand that if I agree to this voluntary admission that I will be prohibited from purchasing, possessing or
transporting firearms until a court issues a restoration order. I further understand that at any time following my
release from this admission, I may petition the general district court in the city or county in which I reside to
restore my right to purchase or possess a firearm. If the court determines that I will not likely act in a manner
dangerous to public safety and that granting the relief would not be contrary to the public interest, the court will
grant me the right to purchase, possess or transport firearms.
I
do or
do not have an advance directive, WRAP Plan or similar crisis plan to help guide my treatment.
I do want ___________________________________________________, ________________________,
(Name of Individual)
(Phone Number)
_______________________________________________________________________________________
(Mailing Address)
notified of my general condition, location and any subsequent transfer to another facility.
I do not want anyone notified of my general condition, location and any subsequent transfer to another facility
Date: ____________, _____________________________________, _______________________________
(Applicant Signature)
(Type or Print Applicant Name)
______________________________________ _____________________
___________ ___________
(Permanent Address/Street, Route No.)
(City/County)
(State)
(Zip Code)
Resident of _____________________________________
County
City
Signed __________________________________
(Patient)
I, the Director or authorized admitting physician, certify that the provisions regarding the rights of a voluntary
patient have been explained and the above named applicant is accepted as a voluntary patient.
Signed _______________________________
(Director or Admitting Physician)
Date Admitted __________________ 20_____ Hour _________________ a.m./p.m.
Register Number _______________________________________________
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