Dhcs 1801 Form – Fill Out and Use This PDF

State of California - Health and Human Services AgencyDepartment of Health Care Services

	APPLICATION FOR ASSESSMENT,			DETAINMENT ADVISEMENT
	EVALUATION, AND CRISIS INTERVENTION			My name is _________________________________
				I am a (Peace Officer, etc.) with (Name of Agency).
	OR PLACEMENT FOR EVALUATION AND
				You are not under criminal arrest, but I am taking you
	TREATMENT
				for examination by mental health professionals at
	Confidential Client/Patient Information			(Name of Facility).
	See California W&I Code Section 5328 and			You will be told your rights by the mental health staff.
	HIPAA Privacy Rule 45 C.F.R. § 164.508
	Welfare and Institutions Code (W&I Code), Section 5150(f) and (g), require that			If taken into custody at his or her residence, the
	each person, when first detained for psychiatric evaluation, be given certain specific			person shall also be told the following information
	information orally and a record be kept of the advisement by the evaluating facility.			You may bring a few personal items with you, which I
	Advisement Complete		Advisement Incomplete	will have to approve. Please inform me if you need
				assistance turning off any appliance or water. You
				may make a phone call and leave a note to tell your
	Good Cause for Incomplete Advisement
				friends or family where you have been taken.
	Advisement Completed By		Position	Language or Modality Used	Date of Advisement

To (name of 5150 designated facility)________________________________________________________________________________________

Application is hereby made for the assessment and evaluation of____________________________________________________________

Residing at ___________________________________________________________________________________________, California, for up to

72- hour assessment, evaluation and crisis intervention or placement for evaluation and treatment at a designated facility pursuant to Section 5150, et seq. (adult) or Section 5585 et seq. (minor), of the W&I Code. If a minor, authorization for voluntary treatment is not available and to the best of my knowledge, the legally responsible party appears to be / is: (Circle one) Parent; Legal Guardian; Juvenile Court under W&I Code 300; Juvenile Court under W&I Code 601/602; Conservator. If known, provide names, address and telephone number:_______________________________________________________

___________________________________________________________________________________________________

___________________________________________________________________________________________________

The above person’s condition was called to my attention under the following circumstances:_______________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

I have probable cause to believe that the person is, as a result of a mental health disorder, a danger to others, or to himself/ herself, or gravely disabled because: (state specific facts)_________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Based upon the above information, there is probable cause to believe that said person is, as a result of mental health disorder:

NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY

Notify (officer/unit & telephone #) ____________________________________________________________________________________________

NOTIFICATION OF PERSON’S RELEASE IS REQUESTED BY THE REFERRING PEACE OFFICER BECAUSE:

The person has been referred to the facility under circumstances which, based upon an allegation of facts regarding actions witnessed by the officer or another person, would support the filing of a criminal complaint.

Weapon was confiscated pursuant to Section 8102 W&I Code. Upon release, facility is required to provide notice to the person regarding the procedure to obtain return of any confiscated firearm pursuant to Section 8102 W&I Code.

SEE REVERSE SIDE REFERENCES AND DEFINITIONS

DHCS 1801 (04/2014)

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State of California - Health and Human Services Agency

Department of Health Care Services

APPLICATION FOR ASSESSMENT,

EVALUATION, AND CRISIS INTERVENTION

OR PLACEMENT FOR EVALUATION AND

TREATMENT

REFERENCES AND DEFINITIONS

“Gravely Disabled” means a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing and shelter. SECTION 5008(h) W&I Code

“Gravely Disabled Minor” means a minor who, as a result of a mental disorder, is unable to use the elements of life which are essential to health, safety, and development, including food, clothing, and shelter, even though provided to the minor by others. Intellectual disability, epilepsy, or other developmental disabilities, alcoholism, other drug abuse, or repeated antisocial behavior do not, by themselves, constitute a mental disorder. SECTION 5585.25 W&I Code

“Peace officer” means a duly sworn peace officer as that term is defined in Chapter 4.5 (commencing with Section 830) of Title 3 of Part 2 of the Penal Code who has completed the basic training course established by the Commission on Peace Officer Standards and Training, or any parole officer or probation officer specified in Section 830.5 of the Penal Code when acting in relation to cases for which he or she has a legally mandated responsibility. SECTION 5008(i) W&I Code

Section 5152.1 W&I Code

The professional person in charge of the facility providing 72-hour evaluation and treatment, or his or her designee, shall notify the county mental health director or the director’s designee and the peace officer who makes the written application pursuant to Section 5150 or a person who is designated by the law enforcement agency that employs the peace officer, when the person has been released after 72- hour detention, when the person is not detained, or when the person is released before the full period of allowable 72-hour detention if all of the conditions apply:

(a)The peace officer requests such notification at the time he or she makes the application and the peace officer certifies at that time in writing that the person has been referred to the facility under circumstances which, based upon an allegation of facts regarding actions witnessed by the officer or another person, would support the filing of a criminal complaint.

(b)The notice is limited to the person’s name, address, date of admission for 72-hour evaluation and treatment, and date of release.

If a police officer, law enforcement agency, or designee of the law enforcement agency, possesses any record of information obtained pursuant to the notification requirements of this section, the officer, agency, or designee shall destroy that record two years after receipt of notification.

Section 5152.2 W&I Code

Each law enforcement agency within a county shall arrange with the county mental health director a method for giving prompt notification to peace officer pursuant to Section 5152.1 W&I Code.

Section 5585.50 W&I Code

The facility shall make every effort to notify the minor's parent or legal guardian as soon as possible after the minor is detained. Section 5585.50 W&I Code.

A minor under the jurisdiction of the Juvenile Court under Section 300 W&I Code is due to abuse, neglect, or exploitation.

A minor under the jurisdiction of the Juvenile Court under Section 601 W&I Code is due to being adjudged a ward of the court as a result of being out of parental control.

A minor under the jurisdiction of the Juvenile Court under Section 602 W&I Code is due to being adjudged a ward of the court because of crimes committed.

Section 8102 W&I Code (EXCERPTS FROM)

(a)Whenever a person who has been detained or apprehended for examination of his or her mental condition or who is a person described in Section 8100 or 8103, is found to own, have in his or her possession or under his or her control, any firearm whatsoever, or any other deadly weapon, the firearm or other deadly weapon shall be confiscated by any law enforcement agency or peace officer, who shall retain custody of the firearm or other deadly weapon.

“Deadly weapon,” as used in this section, has the meaning prescribed by Section 8100.

(b)(1) Upon confiscation of any firearm or other deadly weapon from a person who has been detained or apprehended for examination of his or her mental condition, the peace officer or law enforcement agency shall issue a receipt describing the deadly weapon or any firearm and listing any serial number or other identification on the firearm and shall notify the person of the procedure for the return, sale, transfer, or destruction of any firearm or other deadly weapon which has been confiscated. A peace officer or law enforcement agency that provides the receipt and notification described in Section 33800 of the Penal Code satisfies the receipt and notice requirements.

(2) If the person is released, the professional person in charge of the facility, or his or her designee, shall notify the person of the procedure for the return of any firearm or other deadly weapon which may have been confiscated.

(3) Health facility personnel shall notify the confiscating law enforcement agency upon release of the detained person, and shall make a notation to the effect that the facility provided the required notice to the person regarding the procedure to obtain return of any confiscated firearm.

DHCS 1801 (04/2014)

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