Florida Baker Act Form CF-MH 3052b: Certificate of Professional Initiating Involuntary Examination

Enter the time at which you personally examined the individual, which must be within the preceding 48 hours, with the printed name of the individual, the date and the County; said individual appears to meet criteria for involuntary examination.

Enter your professional license number, then check one box: you are a licensed Psychiatrist, Physician (but not a Psychiatrist), Clinical Psychologist, Psychiatric Nurse, Clinical Social Worker, Mental Health Counselor, Marriage and Family Therapist, Physician Assistant or Advanced Practice Registered Nurse under s. 464.0123 F.S.

There is reason to believe said individual has a mental illness as defined in section 394.455, Florida Statutes: "Mental illness" means an impairment of the mental or emotional processes that exercise conscious control of one's actions or of the ability to perceive or understand reality, which impairment substantially interferes with the individual's ability to meet the ordinary demands of living. For the purposes of this part, the term does not include a developmental disability as defined in chapter 393, intoxication, or conditions manifested only by dementia, traumatic brain injury, antisocial behavior, or substance abuse.

List all mental health diagnoses applicable to this individual & DSM/ICD Codes.

AND because of the mental illness (check all that apply): a. Individual has refused voluntary examination after conscientious explanation and disclosure of the purpose of the examination; OR b. Individual is unable to determine for himself/herself whether examination is necessary; AND

2. Either (check all that apply): a. Without care or treatment said individual is likely to suffer from neglect or refuse to care for himself/herself, and such neglect or refusal poses a real and present threat of substantial harm to his/her well-being and it is not apparent that such harm may be avoided through the help of willing, able, and responsible family members or friends or the provision of other services; OR,

b. There is substantial likelihood that without care or treatment the individual will cause serious bodily harm to (check one or both) self others in the near future, as evidenced by recent behavior.

Document observations supporting the criteria in Section I (including evidence of recent behaviors related to criteria). Include the individual's behaviors and statements, including those specific to suicidal ideation, previous suicide attempts, homicidal ideation or self-injury. If school personnel are involved, describe the nature of their involvement.

If information is obtained from other persons, describe these sources (e.g., reports of family, friends, other mental health professionals or law enforcement officers, as well as medical or mental health records, etc.). Enter other information, including source relied upon to reach this conclusion.

In accordance with 394.4655, F.S.: complete this item ONLY if this involuntary examination is being initiated by a physician as defined by section 394.455(33), F.S. and, in your clinical judgment, the individual has failed or refused to comply with an involuntary outpatient services order.

For Section IV only, a personal examination within the preceding 48 hours is not required. Provide documentation of efforts to solicit compliance with the outpatient services treatment plan.

Provide identifying information (if known) if requested by law enforcement to find the individual so he/she may be taken into custody for examination.

Enter the Age, check Male or Female, and enter the Race/ethnicity.

Enter other details (such as height, weight, hair color, what wearing when last seen, where last seen).

If relevant, enter information such as access to weapon, recent violence or pending criminal charges.

Sign on the Signature of Professional line, then enter the Date Signed, the Time (am or pm), the Printed Name of Professional and the Phone Number (including area code).