Fillable MENTAL ILLNESS ASSESSMENT MAGISTRATE WRITTEN NOTIFICATION FORM (Texas State University)

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MENTAL ILLNESS ASSESSMENT MAGISTRATE WRITTEN NOTIFICATION FORM (Texas State University)

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MENTAL ILLNESS ASSESSMENT MAGISTRATE WRITTEN
NOTIFICATION FORM
MAGISTRATE IS NOT REQUIRED TO ORDER THE COLLECTION OF INFORMATION IF THE DEFENDANT IN THE YEAR
PROCEEDING THE DATE OF APPLICABLE ARREST HAS BEEN DETERMINED TO HAVE A MENTAL ILLNESS OR
INTELLECTUAL DISABILITY BY THE LOCAL MENTAL HEALTH AUTHORITY, LOCAL INTELLECTUAL DEVELOPMENTAL
DISABILITY AUTHORITY, OR ANOTHER MENTAL HEALTH OR INTELLECTUAL DISABILITY EXPERT.
AUTHORITY: 85
TH
LEGISLATIVE SESSION, SENATE BILL 1326
Client Name:
SID Number:
Care Identification #:
DOB:
Last Four Digits of SSN:
Previous Assessment (ANSA) or (CANS):
LIDDA assessment:
*To include but not limited to crisis
assessment
Previously recommended treatment:
Most recent diagnosis(es):
(Date)
Is the client acutely (at time of assessment)
decompensated, suicidal, or homicidal
according to self-report?
Yes / No
If yes, explain:
Other relevant information pertaining to
Mental Health History:
Current County or Municipality of
Incarceration:
Name of Person Submitting Form:
Date of Submission:
Updated 9/1/17
Upon completion of this form, its contents remain confidential as applicable to Health and Safety Code
Chapter 614.017
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MENTAL ILLNESS ASSESSMENT MAGISTRATE WRITTEN NOTIFICATION FORM (Texas State University)

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Completed 19 May 2021

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