Form No Dmh 5 72 01 – Fill Out and Use This PDF

STATE OF NORTH CAROLINA Department of Health and Human Services

Division of Mental Health, Developmental Disabilities, and Substance Abuse Services

County ___________________File # ____________

EXAMINATION AND RECOMMENDATION TO

Client Record # ____________	DETERMINE			Film # ____________
	NECESSITY FOR INVOLUNTARY COMMITMENT
NAME OF RESPONDENT:		AGE	BIRTHDATE	SEX	RACE	M.S.
ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in				County
facility)
				Phone
LEGALLY RESPONSIBLE PERSON	NEXT OF KIN (Name and address)			Relationship
				Phone
PETITIONER (Name and address)				Relationship
				Phone

The above-named respondent was examined on ____________, 20___ at ____________ o’clock ____.M. at ______________

__________________________________________________. Included in the examination was an assessment of the respondent’s:

(1) current and previous mental illness or mental retardation including, if available, previous treatment history; (2) dangerousness to self or others as defined in G.S. 122C-3 (11*); (3) ability to survive safely without inpatient commitment, including the availability of supervision from

family, friends, or others; and (4) capacity to make an informed decision concerning treatment.

(1) current and previous substance abuse

including, if available, previous treatment history; and (2) dangerousness to himself or others as defined in G.S. 122C-3 (11*). The following findings and recommendations are made based on this examination. *See Statutory Definitions on Reverse Side.

SECTION I - CRITERIA FOR COMMITMENT

Outpatient. It is my opinion that:	the respondent is mentally ill
(Physician or Psychologist)	the respondent is capable of surviving safely in the community with available supervision
based upon the respondent’s treatment history, the respondent is in need of treatment in order
to	prevent further disability or deterioration which would predictably result in dangerousness

as defined by G.S. 122C-3 (11*)

the respondent’s current mental status or the nature of his illness limits or negates his/her ability to make an informed decision to seek treatment voluntarily or comply with recommended treatment

SECTION II - DESCRIPTION OF FINDINGS

Clear description of findings (findings for each criterion checked above in Section I must be described):

	(OVER)
Form No. DMH 5-72-01	EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY COMMITMENT
Revised September 2001

SECTION III - RECOMMENDATION FOR DISPOSITION

Inpatient Commitment for _________ days (respondent must be mentally ill and dangerous to self or others)

Outpatient Commitment (respondent must meet ALL of the first four criteria outlined in Section I, Outpatient)

Proposed Outpatient Treatment Center or Physician: (Name)___________________________________________________

(Address and Phone Number)____________________________________________________________________

______________________________________________________________________

Substance Abuse Commitment (respondent must meet both criteria outlined in Section I, Substance Abuse)

Release respondent pending hearing - Referred to:__________________________________________________

Hold respondent at 24-hour facility pending hearing - Facility __________________________________________

Respondent does not meet the criteria for commitment but custody order states that the respondent was charged with a violent crime, including a crime involving assault with a deadly weapon, and that he was found not guilty by reason of insanity or incapable of proceeding: therefore, the respondent will not be released until so ordered following the court hearing.

Respondent or Legally Responsible Person Consented to Voluntary Treatment

Release Respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria) Other (Specify) ______________________________________________________________________________________

		________________________________________________ M.D.			This is to certify that this is a true and exact copy of the
		Physician Signature			Examination and Recommendation for Involuntary Commitment
	____________________________________________________
		Signature/Title - Eligible Psychologist/Qualified Professional			____________________________________________________
					Original Signature - Record Custodian
	____________________________________________________
		Print Name of Examiner			____________________________________________________
					Title
					____________________________________________________
		Address or Facility
					Address or Facility
					____________________________________________________
		City and State
					Date
					NOTE: Only copies to be introduced as evidence need to be certified.
		Telephone Number
		Original: Medical Record

CC:Clerk of Superior Court where petition was initiated (initial hearing only)

Clerk of Superior Court where 24-hour facility is located or where outpatient treatment is supervised

Respondent and State’s Attorneys, when applicable

Proposed Outpatient Treatment Center or Physician (Outpatient Commitment); Area Program / Physician (Substance abuse Commitment) NOTE: If it cannot be reasonably anticipated that the clerk will receive the copies within 48 hours of the time that it was signed, the physician or eligible psychologist/qualified professional shall communicate his findings to the clerk by telephone.

*STATUTORY DEFINITIONS

“Dangerous to self”. Within the recent past: (a) the individual has acted in such a way as to show: (1) that he would be unable without care, supervision, and the continued assistance of others not otherwise available, to exercise self-control, judgment, and discretion in the conduct of his daily responsibilities and social relations or to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety; and (2) that there is a reasonable probability of his suffering serious physical debilitation within the near future unless adequate treatment is given. A showing of behavior that is grossly irrational, of actions that the individual is unable to control, of behavior that is grossly inappropriate to the situation, or of other evidence of severely impaired insight and judgment shall create a prima facie inference that the individual is unable to care for himself; or (b) the individual has attempted suicide or threatened suicide and that there is a reasonable probability of suicide unless adequate treatment is given; or (c) the individual has mutilated himself or attempted to mutilate himself and that there is a reasonable probability of serious self-mutilation unless adequate treatment is given. NOTE: Previous episodes of dangerousness to self, when applicable, may be considered when determining reasonable probability of physical debilitation, suicide, or self-mutilation.

“Dangerous to others”. Within the recent past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of property; and that there is a reasonable probability that this conduct will be repeated. Previous episodes of dangerousness to others, when applicable, may be considered when determining reasonable probability of future dangerous conduct.

“Mental illness:. (a) when applied to an adult, an illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance or control; and (b) when applied to a minor, a mental condition, other than mental retardation alone, that so lessens or impairs the youth’s capacity to exercise age adequate self-control and judgment in the conduct of his activities and social relationships so that he is in need of treatment.

“Substance abuser”. An individual who engages in the pathological use or abuse of alcohol or other drugs in a way or to a degree that produces an impairment in personal, social, or occupational functioning. Substance abuse may include a pattern of tolerance and withdrawal.