Proposed Revocation Of Conditional Discharge
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2FORM 609-7 PROPOSED REVOCATION of CONDITIONAL DISCHARGE-NOTICE
(TEMPORARY –
located on page 2 of this 2 paged document.)
Client Name:___________________________________________ Date of birth: _______________ Date: _______________.
Address: ________________________________________________________in ________________________________County.
The MHC psychiatrist/APRN directed me to commence the PROPOSED on ____________________________________ (date).
The MHC psychiatrist/APRN determined that you created a potentially serious likelihood of danger to self/others as a result
of mental illness. (Explain) Date(s):____________ Time:____________ Location:___________________________________
What happened? __________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Who was present/how was this information confirmed?:____________________________________________________________
The MHC psychiatrist/APRN determined that you violated the following condition(s) of your CD:
1. Take all medications as prescribed. (What meds? Dates missed?): _____________________________________________.
2. Attend regularly scheduled appointments. (Dates of missed appts?) ____________________________________________.
How did missed appointment impact treatment? __________________________________________________________________.
3. Participate in scheduled lab screenings. (Dates of missed labs?): _______________________________________________.
4. In addition to #1, 2, or 3 above, refrain from alcohol/non-prescp/illicit drug use to the extent it adverselyaffected treatment.
Dates of drug/alcohol use:
Times:
Locations:
____ _________________________
What happened?____________________________________________________________ _______________________________
5. (List other condition violated?)___________________________________________________________________________.
6. (List other condition violated?)___________________________________________________________________________.
I EXPLAINED the reasons & OFFERED a copy of the PROPOSED to you before you consented/submitted to an exam.
I INFORMED you that if your CD were absolutely revoked, you would have the right to an administrative hearing.
I used REASONABLE EFFORTS to find you, but I was unable to EXPLAIN & OFFER a copy to you because:
Staff could not locate you at your residence on ___/___/20__ & no one answered or returned a phone call
on ___/____/____.
The # called was (______)________-_________VoiceMail left on _____/____/_____.
It was unsafe to OFFER a copy and EXPLAIN this form to you because of a significant possibility of bodily harm.
My description of the circumstances is detailed below:
(Only execute this section if the client/patient is too dangerous for you to explain and offer this form.)
Date: ___________Time: ___________Location: ________________________________________________________________
What happened? __________________________________________________________________________________________
__________________________________________________________________________________________
Who was present? _________________________________________________________________________________________
The MHC psychiatrist/APRN directed me to give the COMPLAINT (below) to law enforcement on ______________(date).
REQUIRED SIGNATURE
_______________________________-_________________________________________________-_________________
Signature of Psychiatrist, APRN, or Designee
Signer’s Printed Name and Psychiatrist, APRN giving approval
Phone #
******************************************************************
Complaint for Compulsory Examination Pursuant to RSA 135-C:51,II
The undersigned complains that the client named above needs to undergo an examination in accordance with RSA 135-C:51,I, in order to
determine if the client’s conditional discharge should be revoked based on the above allegations set forth in the Notice of Proposed
Revocation of Conditional Discharge (above section). RSA 135-C:51 requires the client to undergo a compulsory examination and I believe
that a reasonable effort has been made to find the client in order to offer and explain the written notice. The client cannot be located or
has been given an opportunity to consent to an examination but refuses to do so. In accordance with RSA 135-C:51, II, I request that a
law enforcement officer take custody of the client and deliver him/her to __________________________________________
NAME OF HOSPITAL
where MHC staff will conduct a compulsory examination for the purpose of determining whether or not the client’s conditional discharge
should be revoked in accordance with RSA 135-C:51, III.
REQUIRED SIGNATURE
_______________________________-_________________________________________________-_________________
Signature of Psychiatrist, APRN, or Designee
Signer’s Printed Name and Psychiatrist, APRN giving approval
Phone #
Effective Date of Form: 07/01/2015
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