Attention Deficit Hyperactivity Disorder (ADHD) and Bipolar Disorder (BD) are two very serious mental illnesses. It is important to be able to recognize the symptoms of each in order to get the necessary help. This form, MH100, is a diagnostic tool used to help identify whether or not an individual meets the criteria for ADHD or BD. There are many benefits to using this form, including getting a more accurate diagnosis and proper treatment. By filling out this form, you can help ensure that you or your loved one gets the best possible care.
| Question | Answer |
|---|---|
| Form Name | Adhs Bhs Form Mh100 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | arizona involuntary evaluation, arizona dbhs form online, arizona dbhs application, az dbhs form |
ADHS/DBHS FORM
APPLICATION FOR INVOLUNTARY EVALUATION
(PURSUANT TO A.R.S. §
STATE OF ARIZONA |
) |
|
) |
COUNTY OF |
) |
To the
(Regional or Screening Authority)
1.The undersigned applicant requests that the above agency conduct a
2.The undersigned applicant alleges that there is now in the County a person whose name and address are:
(Name) |
(Address) |
and that s/he believes that the person has a mental disorder and as a result of said mental disorder, is:
a danger to self;
a danger to others;
gravely disabled;
persistently or acutely disabled
and is:
unwilling to undergo voluntary evaluation, as evidenced by the following facts:
unable to undergo voluntary evaluation, as demonstrated by the following facts:
and who is believed to be in need of supervision, care, and treatment because of the following facts:
3.The conclusion that the person has a mental disorder is based on the following facts:
ADHS/BHS Form |
Page 1 OF 3 |
4.The conclusion that the person is dangerous or disabled is based on the following facts:
|
|
|
|
|
|
|
|
|
|
PERSONAL DATA OF PROPOSED PATIENT: |
|||||||||||||||||
Age |
|
|
Date of Birth |
|
|
Sex |
|
Race |
|
||||||||||||||||||
Weight |
|
|
|
|
Height |
|
|
Hair Color |
|
|
|
|
|
Eye Color |
|||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
Marital Status |
|
|
|
|
|
|
|
|
Number of Children |
|
|||||||||||||||||
Social Security No. |
|
|
Religion |
|
|
|
|
|
|
|
|
||||||||||||||||
Distinguishing Marks |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||||||||||
Occupation |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
Present Location |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||||||
Dates and Places of Previous Hospitalization |
|
|
|
|
|
|
|
|
|||||||||||||||||||
How Long in Arizona |
|
|
State Last From |
|
|||||||||||||||||||||||
Veteran |
|
|
|
|
|
|
|
|
|
|
Education |
|
|||||||||||||||
NAME, ADDRESS AND TELEPHONE NUMBER OF:
1)Guardian
2)Spouse
3)Next of Kin
4)Significant Other Persons
DATE |
SIGNATURE OF APPLICANT |
|||
Printed or Typed Name of Applicant |
|
|||
Relationship to Proposed Patient |
|
|
||
Applicant’s Address |
|
|
||
Applicant’s Telephone |
|
|
||
ADHS/BHS Form |
Page 2 OF 3 |
SUBSCRIBED AND SWORN to before me this |
|
day of |
|
, 20 |
Notary Public
My Commission Expires:
ADHS/BHS Form |
Page 3 OF 3 |