Form Mh 11 – Fill Out and Use This PDF

FORM NO. MH-11

Revised 03/2000

APPLICATION FOR

EMERGENCY EXAMINATION

To the Family Court comes

(Please print full name of applicant)

of

(Please print complete address of applicant)

Telephone Number

Relationship to or interest in proposed patient*

and makes application for the emergency examination of

(Please print full name of proposed person in need of treatment)

of

(Please print complete address of proposed person in need of treatment)

*NOTE: Only the following persons may make application for an individual's emergency examination: a guardian, spouse, parent adult child, close adult relative, a responsible adult friend or person who has the individual in his or her charge or care (e.g. a superintendent of a correctional facility), a law enforcement officer, a licensed physician (Caution: same physician cannot be both applicant and certifying physician), a head of a hospital or his or her written designee, a selectman, a town health officer or a town service officer, or a mental health professional (i.e., a physician, psychologist, social worker, nurse or other qualified person designated by the Commissioner of Developmental and Mental Health Services).

REASON FOR APPLICATION: (State the facts which you have gathered either from your own personal observations or as reliably reported to you by another person which lead you to believe that the proposed patient is in need of emergency examination and which show that the person is a person in need of treatment.)

BE SPECIFIC!

(CONTINUE ON REVERSE SIDE)

FORM NO. MH-11B

Revised: 3/2000

PHYSICIAN'S CERTIFICATE

EMERGENCY EXAM

NOTE TO PHYSICIAN:

If you are considering the proposed patient's admission to a 72 hour hold program: To complete this form you must be a board certified or board eligible psychiatrist, a resident in psychiatry: ONLY THESE PHYSICIANS MAY ADMIT PROPOSED PATIENTS TO THE 72 HOUR HOLD PROGRAM.

If you are considering the proposed patient's admission to Vermont State Hospital: To complete this form you must be a board certified or board eligible psychiatrist, a resident in psychiatry, or a licensed physician designated by the Commissioner of Developmental and Mental Health Services as appropriate to complete Physician' Certificates. Complete Sections I and II.

SECTION I

I, the undersigned, hereby certify that I am a (please circle one) board certified psychiatrist / board eligible psychiatrist / resident in psychiatry/physician designated by Commissioner of Developmental and Mental Health Services as qualified to complete Physician's Certificate. I further state that I am duly licensed to practice medicine in the State of Vermont and I have made careful examination of the mental condition of

			of
	(NAME)			(ADDRESS)
in the County of		, State of Vermont, and that I am of the opinion that he/she is a

mentally ill person in need of treatment. The following information concerning the proposed patient and his or her family is submitted:

DATE OF BIRTH		PLACE OF BIRTH:		SEX:

MARITAL STATUS---Single, Married, Domestic Partner, Divorced, Separated, Widowed, Unknown (Circle One)

NAME AND ADDRESS OF SPOUSE/PARTNER, If any

Can the patient speak and understand English?					If not, what language?
NAME OF FATHER:					ADDRESS:
		(If deceased, so state)
MAIDEN NAME OF MOTHER:					ADDRESS:
	(If deceased, so state					)

(CONTINUED ON REVERSE SIDE)

FORM NO. MH-11D

Revised: 3/2000

SECTION II

PHYSICIAN'S CERTIFICATE

EMERGENCY EXAMINATION

In my opinion this patient

is (A) not only mentally ill, but

(NAME)

(B)poses a danger of harm to him/herself or others and (C) should immediately be admitted to a designated hospital for an emergency examination. I believe the patient meets all three of the above criteria and base this opinion on the facts outlined below. (NOTE: For each of these three criteria, it is required that the physician identify separately facts observed by him or her and those reliably reported to him or her by others. In each case the source must be identified.)

7.What facts have been observed by yourself and/or reliably reported to you which lead you to believe that the patient is mentally ill? What did the patient say? What did the patient do?

Tentative Diagnosis

8.What facts have been observed by yourself and/or reliably reported to you which lead you to believe that as a result of the mental illness the patient poses a danger of harm to him/herself or others? What did the patient say or do? To whom specifically and in what way is the patient a danger?

(CONTINUED ON REVERSE SIDE)