Form Dhcs 1801 - California Application For 72 Hour Detention For Evaluation And Treatment - Health And Human Services Agency
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1
2State of California - Health and Human Services Agency
Department of Health Care Services
DETAINMENT ADVISEMENT
APPLICATION FOR 72 HOUR DETENTION
My name is _________________________________
FOR EVALUATION AND TREATMENT
I am a (Peace Officer, etc.) with (Name of Agency).
You are not under criminal arrest, but I am taking you
Confidential Client/Patient Information
for examination by mental health professionals at
See California W&I Section 5328 and HIPAA
(Name of Facility).
Privacy Rule 45 C.F.R. § 164.508
You will be told your rights by the mental health staff.
Welfare and Institutions Code (W&I), Section 5150(f) and (g), require that each
person, when first detained for psychiatric evaluation, be given certain specific
If taken into custody at his or her residence, the
information orally and a record be kept of the advisement by the evaluating facility.
person shall also be told the following information
Advisement Complete
Advisement Incomplete
You may bring a few personal items with you, which I
will have to approve. Please inform me if you need
Good Cause for Incomplete Advisement
assistance turning off any appliance or water. You
may make a phone call and leave a note to tell your
friends or family where you have been taken.
Advisement Completed By
Position
Language or Modality Used
Date of Advisement
To
_________________________________________________________________________________________________________________________
Application is hereby made for the admission of
____________________________________________________________________________
Residing at
, California, for 72-
___________________________________________________________________________________________
hour treatment and evaluation pursuant to Section 5150, et seq. (adult) or Section 5585 et seq. (minor), of the W&I. If a minor,
authorization for voluntary treatment is not available and to the best of my knowledge, the legally responsible party appears to
be / is: (Circle one) Parent; Legal Guardian; Juvenile Court under W&I 300; Juvenile Court under W&I 601/602; Conservator.
If known, provide names, address and telephone number:
____________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________
* * * * * * * * * *
The above person’s condition was called to my attention under the following circumstances:
I have probable cause to believe that the person is, as a result of a mental health disorder, a danger to others, or to himself/ herself,
or gravely disabled because: (state specific facts)
Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder:
A danger to
A danger to others.
Gravely disabled adult.
Gravely disabled minor.
himself/herself.
Signature, title and badge number of peace officer, professional person in charge of the facility designated by the
Date
Phone
county for evaluation and treatment, member of the attending staff, or professional person designated by the
county.
Time
Name of Law Enforcement Agency or Evaluation Facility/Person
Address of Law Enforcement Agency or Evaluation Facility/Person
NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY
NOTIFICATION OF PERSON’S RELEASE IS REQUESTED BY THE REFERRING PEACE OFFICER BECAUSE:
The person has been referred to the facility under circumstances which, based upon an allegation of facts regarding actions witnessed by the
officer or another person, would support the filing of a criminal complaint.
Weapon was confiscated pursuant to Section 8102 W&I. Upon release, facility is required to provide notice to the person regarding the
procedure to obtain return of any confiscated firearm pursuant to Section 8102 W&I.
Notify (officer/unit & telephone #)
____________________________________________________________________________________________
SEE REVERSE SIDE REFERENCES AND DEFINITIONS
DHCS 1801 (01/2014)
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