Form No Dmh 5 72 01 PDF Details

Form No Dmh 5 72 01 is a request for an exemption from the Department of Mental Health to provide services. The form can be used by providers, family members, or consumers who feel they would benefit from receiving services outside of the Department's regulations. There are several reasons why you may use this form, including but not limited to: residence in a different county, specific diagnosis or treatment needs that are not available through the Department, need for 24-hour care that is not available through the Department, or age 65 and older. If you need more information about Form No Dmh 5 72 01 or any other forms related to mental health services, please visit our website at Thank you for your interest in mental health services in Massachusetts!

Form NameForm No Dmh 5 72 01
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other namesnc ivc forms, 2001, ivc paperwork, debilitation

Form Preview Example

STATE OF NORTH CAROLINA Department of Health and Human Services

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

County ___________________File # ____________


Client Record # ____________


Film # ____________























ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in


















NEXT OF KIN (Name and address)

















PETITIONER (Name and address)






















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.


Inpatient. It is my opinion that the respondent is: (1st Exam - Physician or Psychologist)

(2nd Exam - Physician only)

mentally ill;

dangerous to self;

dangerous to others

In addition to being mentally ill is also mentally retarded

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


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

Substance Abuse. It is my opinion that the respondent is: (1st Exam -Physician or Psychologist; 2nd Exam - If 1st

exam done by Physician, 2nd exam may be done by Qual. Prof.)

a substance abuser dangerous to himself or others


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





Form No. DMH 5-72-01


Revised September 2001


Notable Physical Conditions:


Current Medications (medical and psychiatric)


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

















Address or Facility






Address or Facility









City and State













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.


“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.

How to Edit Form No Dmh 5 72 01 Online for Free

You may fill in 122C-3 effectively using our PDFinity® PDF editor. FormsPal professional team is always endeavoring to improve the tool and insure that it is even better for people with its many functions. Take full advantage of present-day innovative opportunities, and discover a trove of unique experiences! With just a couple of easy steps, you can start your PDF journey:

Step 1: Simply click the "Get Form Button" above on this webpage to access our form editing tool. This way, you will find all that is needed to work with your document.

Step 2: Using this advanced PDF tool, you may do more than simply complete blanks. Express yourself and make your forms appear perfect with customized textual content added in, or optimize the file's original input to excellence - all accompanied by the capability to insert your own images and sign it off.

This PDF will need particular information to be filled in, hence you should take some time to fill in what's expected:

1. Start filling out the 122C-3 with a number of necessary blanks. Gather all of the required information and ensure not a single thing forgotten!

How you can fill in dmh 5 72 19 part 1

2. Immediately after the last selection of fields is completed, go to type in the applicable information in all these: SECTION I CRITERIA FOR COMMITMENT, Inpatient It is my opinion that, mentally ill, dangerous to others In addition to, dangerous to self, the respondent is mentally ill the, the respondents current mental, ability to make an informed, Substance Abuse It is my opinion, a substance abuser dangerous to, SECTION II DESCRIPTION OF FINDINGS, and Clear description of findings.

Stage number 2 for completing dmh 5 72 19

Always be very careful while filling in Clear description of findings and mentally ill, because this is the part in which many people make mistakes.

3. This subsequent part should also be quite straightforward, Notable Physical Conditions, ImpressionDiagnosis, Current Medications medical and, SECTION III RECOMMENDATION FOR, Inpatient Commitment for days, Proposed Outpatient Treatment, Substance Abuse Commitment, Release respondent pending hearing, Respondent does not meet the, violent crime including a crime, Respondent or Legally Responsible, Physician Signature, Print Name of Examiner, Original Signature Record, and MD SignatureTitle Eligible - these blanks will have to be filled out here.

How to fill in dmh 5 72 19 step 3

4. The fourth part comes with the next few fields to complete: Print Name of Examiner, MD SignatureTitle Eligible, This is to certify that this is a, Address or Facility, City and State, Telephone Number, Address or Facility, Date, Title, STATUTORY DEFINITIONS, and Dangerous to self Within the.

dmh 5 72 19 writing process described (portion 4)

Step 3: Always make sure that your details are right and then simply click "Done" to complete the process. Join FormsPal right now and instantly get 122C-3, available for download. Every edit you make is conveniently kept , which enables you to change the file later when required. Here at FormsPal, we endeavor to be certain that all of your information is kept private.