DHCS 1801 at a glance
What it is: DHCS 1801 is the Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment.
Who signs: One of these signs, with title and badge number: a peace officer, the professional person in charge of the facility designated by the county for evaluation and treatment, a member of the attending staff, a designated member of a mobile crisis team, or a professional person designated by the county.
Peace officer, professional person in charge of the facility designated by the county for evaluation and treatment, member of the attending staff, designated members of a mobile crisis team, or professional person designated by the county.
A filled-in DHCS 1801 example: a deputy applies for a 72-hour evaluation
How to fill out DHCS 1801, box by box
Complete Advisement, Incomplete Advisement and Good Cause for Incomplete Advisement
Welfare and Institutions Code (W&I Code), section 5150(g)(1), requires that each person, at the time they are first taken into custody under this section, shall be provided, by the person who takes them into custody, the information orally in a language or modality accessible to the person. If the person cannot understand an oral advisement, the information shall be provided in writing.
Detainment Advisement: My name is (your name). I am a (peace officer/behavioral health professional) with (name of agency). You are not under criminal arrest, but I am taking you for examination by behavioral health professionals at (name of facility). You will be told your rights by the behavioral health staff. If taken into custody at their residence, the person shall also be told the following: You may bring a few personal items with you, which I 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 friends or family where you have been taken.
Mark Complete Advisement or Incomplete Advisement, and enter the Date of Advisement/Attempt.
For an Incomplete Advisement, enter the Good Cause for Incomplete Advisement.
Enter Advisement Completed/Attempted By, Position and Language or Modality Used.
Application is hereby made for the assessment and evaluation of
Enter the name of the 5150 designated facility after To.
Enter the person detained after Application is hereby made for the assessment and evaluation of, then date of birth, then and residing at, California.
Enter the Detainment Start Date and the Detainment Start Time. The 72-hour period begins at the time when the person is first detained.
Minor/conservatee: legal authority and juvenile court
If the authorization for voluntary treatment is not available for a minor/conservatee, indicate to the best of your knowledge who has legal authority to make medical decisions on behalf of the minor/conservatee: (name & contact information, if available).
(Check one): Parent(s), Legal Guardian(s), Conservator or Other.
Indicate to the best of your knowledge whether the minor is under the jurisdiction of the juvenile court (Check one): W&I Code 300 (dependent) or W&I Code 601, 602 (ward).
The detained person's condition and the specific facts
Under The detained person's condition was called to my attention under the following circumstances: write the circumstances.
Write the specific facts that you have considered that lead you to believe that this person is a danger to self or others as a result of a mental health disorder or gravely disabled as a result of a mental health disorder, a severe substance use disorder, or a co-occurring mental health disorder and a severe substance use disorder.
I have considered the historical course, No reasonable bearing on the determination or No information because
Mark I have considered the historical course, and write the historical course of the person's mental health disorder, severe substance use disorder, or co-occurring mental health disorder and a severe substance use disorder, as follows.
Mark No reasonable bearing on the determination, or mark No information because: and write why.
History Provided by (Name), Address, Phone Number and Relation
Optional Information: enter History Provided by (Name), Address, Phone Number and Relation.
Probable cause to believe said person is a
There is probable cause to believe that said person is a:
Danger to Self (DTS) as a result of a mental health disorder.
Danger to Others (DTO) as a result of a mental health disorder.
Gravely disabled adult as a result of a mental health disorder.
Gravely disabled adult due to severe substance use disorder.
Gravely disabled adult due to co-occurring mental health disorder and severe substance use disorder (as defined in W&I Code section 5008(h)).
Gravely disabled minor as a result of a mental health disorder (as defined in W&I Code section 5585.25).
Notifications to be Provided Pursuant to Section 5152.1 and/or 8102
Under Notifications to be Provided Pursuant to Section 5152.1 and/or 8102 of the W&I Code, enter the Name and Phone of the behavioral health director/designee and of the peace officer/designee to notify of the person's release or end of detention if either of the boxes below are checked.
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 W&I Code Section 8102.
Signature, title, and badge number
Enter the Name of Law Enforcement Agency or Evaluation Facility/Person, then the Address, City, State and Zip Code.
Enter the Name, Title, Badge Number and Phone, sign on the Signature line, then enter the Date and the Time.
References: Individual Detained and Date of Birth
Under References, enter the Individual Detained and the Date of Birth.
More rules for DHCS 1801
A copy of this application shall be treated as the original.
Sources
[1] DHCS 1801 (Revised 03/2026), Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment, California Department of Health Care Services (the Official source link on this page).