Notable Physical Conditions: Current Medications (medical and psychiatric)
Impression/Diagnosis:
SECTION III - RECOMMENDATION FOR DISPOSITION
Inpatient Commitment for _________ days (respondent must be mentally ill and dangerous to self or others)
Outpatient Commitment (respondent must meet ALL of the first four criteria outlined in Section I, Outpatient)
Proposed Outpatient Treatment Center or Physician: (Name)___________________________________________________
(Address and Phone Number)____________________________________________________________________
____________________________________________________________
LME notified of appointment: (Name of LME and date)__________________________________________________________
Substance Abuse Commitment (respondent must meet both criteria outlined in Section I, Substance Abuse)
Release respondent pending hearing - Referred to:__________________________________________________
Hold respondent at 24-hour facility pending hearing – Facility: __________________________________________
Respondent does not meet the criteria for commitment but custody order states that the respondent was charged with a
violent crime, including a crime involving assault with a deadly weapon, and that he was found not guilty by reason of insanity or
incapable of proceeding: therefore, the respondent will not be released until so ordered following the court hearing.
Respondent or Legally Responsible Person Consented to Voluntary Treatment
Release Respondent and Terminate Proceedings
(insufficient findings to indicate that respondent meets commitment criteria)
Respondent was held 7 days from issuance of custody order but continues to meet commitment criteria. A new petition will be filed.
Other
(Specify) ______________________________________________________________________________________
________________________________________
M.D.
Physician Signature
__________________________________________________________
Signature/Title – Eligible Psychologist/Qualified Professional
____________________________________________________________
Print Name of Examiner
___________________________________________________________
Address or Facility
____________________________________________________________
City and State
Telephone Number
This is to certify that this is a true and exact copy of the Examination and
Recommendation for Involuntary Commitment
Original Signature – Record Custodian
Title
Address or Facility
Date
NOTE: Only copies to be introduced as evidence need to be certified
CC: Clerk of Superior Court where petition was initiated (initial hearing only)
Clerk of Superior Court where 24-hour facility is located or where outpatient treatment is supervised
Respondent or Respondent’s Attorney and State’s Attorneys, when applicable
Proposed Outpatient Treatment Center or Physician (Outpatient Commitment); Area Program / Physician (Substance Abuse Commitment)
NOTE: If it cannot be reasonably anticipated that the clerk will receive the copies within 48 hours of the time that it was signed, the physician
or eligible psychologist/qualified professional shall communicate his findings to the clerk by telephone.
*STATUTORY DEFINITIONS
“Dangerous to self”. Within the relevant past: (a) the individual has acted in such a way as to show: (1) that he would be unable without care,
supervision, and the continued assistance of others not otherwise available, to exercise self-control, judgment, and discretion in the conduct of
his daily responsibilities and social relations or to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and
safety; and (2) that there is a reasonable probability of his suffering serious physical debilitation within the near future unless adequate treatment
is given. A showing of behavior that is grossly irrational, of actions that the individual is unable to control, of behavior that is grossly inappropriate
to the situation, or of other evidence of severely impaired insight and judgment shall create a prima facie inference that the individual is unable
to care for himself; or (b) the individual has attempted suicide or threatened suicide and that there is a reasonable probability of suicide unless
adequate treatment is given; or (c) the individual has mutilated himself or attempted to mutilate himself and that there is a reasonable probability
of serious self-mutilation unless adequate treatment is given. NOTE: Previous episodes of dangerousness to self, when applicable, may be
considered when determining reasonable probability of physical debilitation, suicide, or self-mutilation.
“Dangerous to others”. Within the relevant past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on
another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of
property; and that there is a reasonable probability that this conduct will be repeated. Previous episodes of dangerousness to others, when
applicable, may be considered when determining reasonable probability of future dangerous conduct.
“Mental illness:. (a) when applied to an adult, an illness which so lessens the capacity of the individual to use self-control, judgment, and
discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision,
guidance or control; and (b) when applied to a minor, a mental condition, other than mental retardation alone, that so lessens or impairs the
youth’s capacity to exercise age adequate self-control and judgment in
the conduct of his activities and social relationships so that he is in need of treatment.
“Substance abuser”. An individual who engages in the pathological use or abuse of alcohol or other drugs in a way or to a degree that
produces an impairment in personal, social, or occupational functioning. Substance abuse may include a pattern of tolerance and withdrawal.
