Detention Form – Fill Out and Use This PDF

LIST OF CIVIL INVOLUNTARY DETENTION FORMS:

MENTAL HEALTH AND ALCOHOL AND DRUG

DMH 128

Application to Court for 96 Hour Detention, Evaluation and Treatment/Rehabilitation

 Used to apply to court for 96 hour detention for mental health and alcohol and drug

 Completed by any adult person

 Must have Affidavits (DMH 142) and Witness List (DMH 137) attached

 Must be notarized

 Presented to the Probate Court in the county where the person may be found

 Copies provided within 3 hours to the Client

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*DMH 129

Order for 96 Hour Detention, Evaluation and Treatment/Rehabilitation

 Order for 96 hour detention for mental health and alcohol and drug

 Issued by the Probate Court in the county where the person may be found

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*OSCA MH15

Order for 96 Hour Detention, Treatment and Rehabilitation and Warrant (MH)

 Order for 96 hour detention for mental health only

 Plus a Warrant for Law Enforcement to assume custody and transport

 Issued by the Probate Court in the county where the person may be found

 Executed and signed by the Sheriff

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*OSCA MH20

Order for 96 Hour Detention, Treatment and Rehabilitation and Warrant (A&D)

 Order for 96 hour detention for alcohol and drug only

 Plus a Warrant for Law Enforcement to assume custody and transport

 Issued by the Probate Court in the county where the person may be found

 Executed and signed by the Sheriff and returned to the Probate Court

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*DMH 130

Warrant

 Warrant for Law Enforcement to assume custody and transport

 Issued by the Probate Court in the county where the person may be found

 Executed and signed by the Sheriff and returned to the Probate Court

DMH 131

Request for Transportation to Mental Health Facility/Alcohol and Drug Abuse Facility

 Mental Health Coordinator form to request transportation by law enforcement

DMH 132

Application for 96 Hour Imminent Harm Admission to Mental Health/Alcohol & Drug Abuse Facility

 Used to apply for 96 hour detention for mental health and alcohol and drug

 Completed by Peace Officer or Facility Designee

 Must have Affidavits (DMH 142) and Witness List (DMH 137) attached

 Must be notarized

 Presented to the Head of the Facility

 Copies provided within 3 hours to the Client

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

Application for 96 Hour Detention, Evaluation, and Treatment/Rehabilitation of a Voluntary Patient

DMH 133

Requesting Release

 Used to apply for 96 hour detention for mental health and alcohol and drug for a voluntary client who is

requesting release

 Completed by Facility Designee

 Must have Affidavits (DMH 142) and Witness List (DMH 137) attached

 Must be notarized

 Presented to the Head of the Facility

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 Copies provided within 3 hours to the Client

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

DMH 134-1

Petition for Involuntary Detention and Treatment

 Used to apply for detention beyond 96 hours for mental health and alcohol and drug

 Completed by Facility Designee

 Must have Verification (DMH 134-2) and Witness List (DMH 137) attached

 Original presented to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, Prosecuting Attorney and Department of Mental Health

 Court will serve the Client and the Client’s Attorney with the Petition

DMH 134-2

Verification

 Used with Petition (DMH 134-1 to apply for detention beyond 96 hours for mental health and alcohol

and drug

 For mental health, completed by: 1) a psychiatrist or by 2) a licensed physician and a mental health

professional

 For alcohol and drug, completed by a licensed physician

 Original presented to the Probate Court in the county where the facility is

 Copies to Medical Record, Client, Client’s Attorney, Prosecuting Attorney and Department of Mental

Health

*DMH 135

Order Setting Hearing on Application for Additional Detention and Treatment and Confirming

 Issued by the Probate Court setting the date and time for the hearing, continuing the service of the

attorney and ordering all records made available to the attorney for mental health and alcohol and

drug

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

*OSCA MH25

Order Setting Hearing on Petition for Additional Detention and Treatment and Confirming

 Issued by the Probate Court setting the date and time for the hearing, continuing the service of the

attorney and ordering all facility records made available to the attorney for mental health only (OSCA

form)

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

*OSCA MH30

Order Setting Hearing on Petition for Additional Detention and Treatment and Confirming

 Issued by the Probate Court setting the date and time for the hearing, continuing the service of the

attorney and ordering all facility records made available to the attorney for alcohol and drug only

(OSCA form)

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

*DMH 136

Judgment for Involuntary Inpatient Detention and Treatment/Rehabilitation

 Issued by the Probate Court order further detention for mental health and alcohol and drug

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

*OSCA MH35

Judgment for Involuntary Detention and Treatment (MH)

 Issued by the Probate Court order further detention for mental health only (OSCA form)

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

*OSCA MH40

Judgment for Involuntary Detention and Treatment (A&D)

 Issued by the Probate Court order further detention for alcohol and drug only (OSCA form)

 Copies distributed by the Probate Court. The facility should ensure that copies go to the Client,

Client’s Chart , Client’s Attorney, Department of Mental Health

DMH 137

List of Witnesses

 Completed for all 96 hour applications; Court DMH 128, Imminent Harm DMH 132, Voluntary to

Involuntary DMH 133 and Petition DMH 143-1 for mental health and alcohol and drug

 Completed by the applicant

 Lists names, addresses and telephone numbers of any prospective witnesses

 Presented to the Probate Court with a DMH 128 or DMH 134-1 Application

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 Presented to the Head of the Facility with a DMH 132 or DMH 133 Application

 Copies to Medical Record, Client’s Attorney, Prosecuting Attorney and Department of Mental Health

 Court will serve the Client and the Client’s Attorney with the List of Witnesses

DMH 138

Notice of Admission of Involuntary Patient

 Completed by the Head of the Facility upon the admission of an involuntary client for mental health

and alcohol and drug

 Copies provided within 3 hours to the Client

 Provides the date of admission, proof that notice of rights was given and name of the attorney

designated from the list provided by the Probate Court

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

DMH 139

Withdrawal Petition (MH)

 Completed by the applicant, most usually the Head of the Facility, withdrawing the petition for further

detention and stating the reasons why for mental health

 Presented to the Probate Court in the county where the facility is along with DMH 147 Notice of

Discharge/Voluntary Admission

 Copies to Client, Medical Record, Client’s Attorney, Prosecuting Attorney and Department of Mental

Health

DMH 8537

Withdrawal Petition (A&D)

 Completed by the applicant, most usually the Head of the Facility, withdrawing the petition for further

detention and stating the reasons why for alcohol and drug

 Presented to the Probate Court in the county where the facility is along with DMH 147 Notice of

Discharge/Voluntary Admission

 Copies to Client, Medical Record, Client’s Attorney, Prosecuting Attorney and Department of Mental

Health

DMH 140

Application for Order Appointing Independent Physician/Psychologist

 Filed by the client’s attorney requesting the Probate Court to appoint a licensed physician or

psychologist to examiner the client and testify on his behalf at hearings for detention beyond 21 days

for mental health only

*DMH 141

Order Appointing Independent Physician/Psychologist

 Issued by the Probate Court appointing a licensed physician or psychologist to examiner the client and

testify on his or her behalf at hearings for detention beyond 21 days for mental health only

*OSCA MH45

Order Appointing Independent Physician/Psychologist

 Issued by the Probate Court appointing a licensed physician or psychologist to examiner the client and

testify on his or her behalf at hearings for detention beyond 21 days for mental health only (OSCA

form)

DMH 142

Affidavit in Support of Application for Detention, Evaluation and Treatment/Rehabilitation –

 Used to support an application (DMH 128, DMH 132, DMH 133) for 96 hour detention for mental

health and alcohol and drug

 Completed by any adult person

 Describes the behavior that supports that the client presents a likelihood of serious harm as the result

of mental disorder or alcohol or drug abuse

 Must describe behavior that supports  the presence of a mental disorder and the likelihood of

harm as the result of the mental disorder

 Must be notarized

 Presented to the Probate Court with a DMH 128 Application

 Presented to the Head of the Facility with a DMH 132 or DMH 133 Application

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*DMH 143

Notice of Hearing on Petition for Additional Detention and Treatment

 Issued by the Probate Court providing notice to the client and the client’s attorney that a petition for

further detention has been filed and provides the date and time of the hearing for mental health and

alcohol and drug

 Served by the Sheriff

*OSCA MH26

Notice of Hearing on Petition for Additional Detention and Treatment (MH)

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 Issued by the Probate Court providing notice to the client and the client’s attorney that a petition for

further detention has been filed and provides the date and time of the hearing for mental health only

 Served by the Sheriff (OSCA form)

*OSCA MH31

Notice of Hearing on Petition for Additional Detention and Treatment (A&D)

 Issued by the Probate Court providing notice to the client and the client’s attorney that a petition for

further detention has been filed and provides the date and time of the hearing for alcohol and drug

only

 Served by the Sheriff (OSCA form)

DMH 145

Notice of Rights of Involuntary Patient

 Presented to any person admitted for 96 hour detention for mental health and alcohol and drug

 Must be presented within to client 3 hours of admission

 Provided within 8 hours to guardian or with consent to family

 A staff member must have the client read the rights or must read the rights to the person

 The staff member must sign the form

 Copies sent within 24 hours to the Probate Court in the county where the facility is

 Copies to Medical Record, Client’s Attorney, and Department of Mental Health

*DMH 146

Order for Release

 Issued by the Probate Court when the client is found not to meet criteria for further detention for

mental health and alcohol and drug

*OSCA MH50

Order for Release (MH)

 Issued by the Probate Court when the client is found not to meet criteria for further detention for

mental health only (OSCA form)

*OSCA MH55

Order for Release (A&D)

 Issued by the Probate Court when the client is found not to meet criteria for further detention for

alcohol and drug only (OSCA form)

DMH 147

Notice of Discharge/Voluntary Admission (MH)

 Completed by the Head of the Facility to notify the Probate Court of the client’s discharge or voluntary

admission for mental health

 Ends the commitment

 Copies sent to the Probate Court in the county where the facility is

 Copies to Client, Medical Record, Client’s Attorney, and Department of Mental Health

DMH 8543

Notice of Discharge/Voluntary Admission (A&D)

 Completed by the Head of the Facility to notify the Probate Court of the client’s discharge or voluntary

admission for alcohol and drug

 Ends the commitment

 Copies sent to the Probate Court in the county where the facility is

 Copies to Client, Medical Record, Client’s Attorney, and Department of Mental Health

DMH 148

Request for Change of Venue to Respondent's County of Residence (MH)

 Presented to the Probate Court requesting that the hearing for further detention be held in the client’s

county of residence for mental health

 Completed by the client, or the client’s parent or guardian or attorney

DMH 8544

Request for Change of Venue to Respondent's County of Residence (A&D)

 Presented to the Probate Court requesting that the hearing for further detention be held in the client’s

county of residence for alcohol and drug

 Completed by the client, or the client’s parent or guardian or attorney

DMH 149

Order for Change of Venue to Respondent's County of Residence (MH)

 Issued by the Probate Court ordering that the hearing for further detention be held in the client’s

county of residence for mental health

DMH 8545

Order for Change of Venue to Respondent's County of Residence (A&D)

 Issued by the Probate Court ordering that the hearing for further detention be held in the client’s

county of residence for alcohol and drug

DMH 150

Conditional Release for Involuntarily Detained Patient

 Used to place a detained client on conditional release in the community for mental health

 Completed by the Head of the Facility and signed by the client and mental health professional

 Specifics conditions of release, follow-up care and the provider

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 Copies sent to the Probate Court in the county where the facility is

 Copies to Client, Medical Record, Client’s Attorney, and Department of Mental Health

DMH 151

Notice to Patient of Revocation of Conditional Release

 Used by the Head of the Facility to revoke the conditional release

 The Probate Court may order the law enforcement to detain and transport the client the mental health

facility

 The Probate Court may order a hearing on the revocation of conditional release

 Copies sent to the Probate Court in the county where the facility is

 Copies to Client, Medical Record, Client’s Attorney, and Department of Mental Health

DMH 152

Request for Hearing on Revocation of Conditional Release

 Completed by the client to request that the Probate Court hold a hearing on the revocation of

conditional release

DMH 153

Trial Visit for Involuntarily Detained Patient