1. Comes the Aant, ____________________________________________, and states that he/she is a Qualied Health
Professional as dened in KRS Chapter 222, and he/she is,
q A Qualied Mental Health Professional as dened in KRS 202A.011; and/or
q An Alcohol and Drug Counselor certied under KRS Chapter 309; and/or
q A Physician, licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical ocer of the
government of the United States while engaged in the performance of ocial duties.
2. Aant further states that he/she examined the above-named Respondent and based on that examination, in his/her
professional opinion, the Respondent
A.
q does q does not suer from a substance use disorder; and
B. q does q does not present an imminent threat of danger to self, family or others as a result of a substance
use disorder; or there
q does q does not exist a substantial likelihood of such a threat in the near future; and
C. q can q cannot reasonably benet from treatment.
3. The facts that support Aant's belief that Respondent does suer from a substance use disorder:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. The facts that support Aant's belief that Respondent presents an imminent threat of danger to self, family or others as a
result of a substance use disorder or that there exists a substantial likelihood of such a threat in the near future:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Diagnostic impressions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________

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
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AOC-703A Doc. Code: CIT
Rev. 6-19
Page 1 of 3
Commonwealth of Kentucky
Court of Justice www.courts.ky.gov
KRS 222.005; 222.431; 222.433
Case No. ____________________
Court ________________________
County ______________________
Division ______________________
District
IN THE INTEREST OF:
RESPONDENT_____________________________________________________
AOC-703A
Rev. 6-19
Page 2 of 3
6. Other factors contributing to need for treatment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. Goal of treatment and recommendation for treatment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Date examination was performed: ______________________________, 2_____
Further, Aant sayeth naught.
 The Respondent shall be examined no later than twenty-four (24) hours before the hearing date by two (2) Qualied Health
Professionals, at least one (1) of whom is a physician. A separate Certication of Qualied Health Professional (AOC-703A) must
be led with the Court by each of the two (2) Qualied Heath Professionals named in the Hearing, Examination and Appointment
of Counsel Notice and Order (AOC-701A). The Qualied Health Professionals shall certify their ndings to the Court within twenty-
four (24) hours of the examination. See page 3 for more information on Qualied Health Professionals.

____________________________________________
Signature of QHP
_____________________________, 2_____
Date
____________________________________________
Name of QHP (please print)
____________________________________________
Title of QHP (please print)
____________________________________________
Name of Treatment Facility of QHP (please print)
____________________________________________
Notary Public
My Commission Expires: _________________________
Subscribed and sworn to before me this ________ day of __________________________, 2______
____________________________________________
County, Kentucky
Print
Reset Form

     


 has the same meaning as qualied mental health professional in KRS 202A.011, except that it also
includes an alcohol and drug counselor certied under KRS Chapter 309.

a. A  licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical ocer of the
government of the United States while engaged in the performance of ocial duties.
b. A  licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical ocer of the
government of the United States while engaged in the practice of ocial duties, who is certied or eligible to apply
for certication by the American Board of Psychiatry and Neurology, Inc.
c. A  with the health service provider designation, a  , a c ,
or a , licensed under the provisions of KRS Chapter 319.
d. A    with a master’s degree in psychiatric nursing from an accredited institution and two
(2) years of clinical experience with mentally ill persons; or a licensed registered nurse, with a bachelor’s degree
in nursing from an accredited institution, who is certied as a psychiatric and mental health nurse by the American
Nurses Association and who has three (3) years of inpatient or outpatient clinical experience in psychiatric nursing
and is currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric
unit of a general hospital or a private agency or company engaged in provision of mental health services or a regional
community program for mental health and individuals with an intellectual disability.
e. A     licensed under the provisions of KRS 335.100, or a certied social worker licensed
under the provisions of KRS 335.080 with three (3) years of inpatient or outpatient clinical experience in psychiatric
social work and currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or
a psychiatric unit of a general hospital or a private agency or company engaged in the provision of mental health
services or a regional community program for mental health and individuals with an intellectual disability.
f. A     licensed under the provisions of KRS 335.300 to 335.399 with three (3) years
of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a
hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency
or company engaged in providing mental health services, or a regional community program for mental health and
individuals with an intellectual disability.
g. A   credentialed under the provisions of KRS Chapter 335.500 to 335.599 with three (3)
years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a
hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency
or company engaged in providing mental health services, or a regional community program for mental health and
individuals with an intellectual disability.
h. A licensed under KRS 311.840 to 311.862, who meets one (1) of the following requirements:
1. Provides documentation that he or she has completed a psychiatric residency program for physician assistants;
2. Has completed at least one thousand (1,000) hours of clinical experience under a supervising physician, as dened by KRS 311.840,
who is a psychiatrist and is certied or eligible for certication by the American Board of Psychiatry and Neurology, Inc.;
3. Holds a master's degree from a physician assistant program accredited by the Accreditation Review Commission on Education for the
Physician Assistant or its predecessor or successor agencies, is practicing under a supervising physician as dened by KRS 311.840,
and:
a. Has two (2) years of clinical experience in the assessment, evaluation, and treatment of mental disorders; or
b. Has been employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general
hospital or a private agency or company engaged in the provision of mental health services or a regional community program for
mental health and individuals with an intellectual disability for at least two (2) years; or
4. Holds a bachelor's degree, possesses a current physician assistant certicate issued by the board prior to July 15, 2002, is practicing
under a supervising physician as dened by KRS 311.840, and:
a. Has three (3) years of clinical experience in the assessment, evaluation, and treatment of mental disorders; or
b. Has been employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general
hospital or a private agency or company engaged in the provision of mental health services or a regional community program for
mental health and individuals with an intellectual disability for at least three (3) years.
 a person certied by the Kentucky Board of Alcohol and Drug
Counselors pursuant to KRS 309.080 to 309.089.
AOC-703A
Rev. 6-19
Page 3 of 3
