Form Dmh 5-72-01 - Examination And Recommendation For Ivc Form - Department Of Health And Human Services - North Carolina
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2STATE OF NORTH CAROLINA Department of Health and Human Services
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
County ___________________
File # ____________
EXAMINATION AND RECOMMENDATION TO
Client Record # ____________
Film # ____________
DETERMINE
NECESSITY FOR INVOLUNTARY COMMITMENT
NAME OF RESPONDENT:
AGE
BIRTHDATE
SEX
RACE
M.S.
ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in
County
facility)
Phone
LEGALLY RESPONSIBLE PERSON
NEXT OF KIN (Name and address)
Relationship
Phone
PETITIONER
(Name and address)
Relationship
Phone
The above-named respondent was examined on ____________, 20___ at ____________ o’clock ____.M. at ______________
__________________________________________________. Included in the examination was an assessment of the respondent’s:
(1) current and previous mental illness or mental retardation including, if available, previous treatment history; (2) dangerousness to self or
others as defined in G.S. 122C-3 (11*); (3) ability to survive safely without inpatient commitment, including the availability of supervision from
family, friends, or others; and (4) capacity to make an informed decision concerning treatment.
(1) current and previous substance abuse
including, if available, previous treatment history; and (2) dangerousness to himself or others as defined in G.S. 122C-3 (11*). The following
findings and recommendations are made based on this examination. *See Statutory Definitions on Reverse Side.
SECTION I - CRITERIA FOR COMMITMENT
Inpatient. It is my opinion that the respondent is:
mentally ill;
dangerous to self;
dangerous to others
(1st Exam - Physician or Psychologist)
In addition to being mentally ill is also mentally retarded
(2nd Exam - Physician only)
Outpatient. It is my opinion that:
the respondent is mentally ill
(Physician or Psychologist)
the respondent is capable of surviving safely in the community with available supervision
based upon the respondent’s treatment history, the respondent is in need of treatment in order
to prevent further disability or deterioration which would predictably result in dangerousness
as defined by G.S. 122C-3 (11*)
the respondent’s current mental status or the nature of his illness limits or negates his/her
ability to make an informed decision to seek treatment voluntarily or comply with
recommended treatment
Substance Abuse. It is my opinion that the respondent is:
a substance abuser
(1st Exam -Physician or Psychologist; 2nd Exam - If 1st
dangerous to himself or others
exam done by Physician, 2nd exam may be done by Qual. Prof.)
SECTION II - DESCRIPTION OF FINDINGS
Clear description of findings (findings for each criterion checked above in Section I must be described):
(over)
Form No. DMH 5-72-01
EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY COMMITMENT
Revised September 2001
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