Mh 302 Form PDF Details

In the realm of mental health care and emergency intervention, the MH 302 form represents a critical juncture between personal freedoms and the necessity of providing immediate care. Crafted by the Santa Clara County Department of Mental Health, this document facilitates a 72-hour detention for evaluation and treatment of individuals deemed a danger to themselves, others, or gravely disabled due to a mental disorder. Its roots stretch deeply into the rich soil of legal and ethical consideration, particularly reflecting the nuanced balance required by the Welfare and Institutions Code (WIC), Section 5157, and the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, underscoring the intersection of care, rights, and privacy. The form is both a procedural guide and a record, starting from the advisement of detainment, where the individual is informed by a peace officer or similar agent of their non-criminal status but necessity for evaluation, through to the detailed capture of the individual's condition and the circumstances that led to the intervention. Completeness, accuracy, and sensitivity in filling out the form are paramount, as it steers the initial phase of potentially life-saving intervention while navigating the individual's rights and dignity. Every section, from the detainment advisement to the application for admission, from the detailed behavioral observations to the final signatures and notifications, forms a fabric of information crucial for the immediate and respectful care of the person in crisis. As such, the MH 302 form is a testament to the challenges and responsibilities of mental health professionals, law enforcement, and society in addressing the complex interplay of mental health crises.

QuestionAnswer
Form NameMh 302 Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other nameshuman mh 302, mh 302, what is a 302 form, mh 302 form

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Santa Clara County Department of Mental Health MH 302

APPLICATION FOR 72 HOUR DETENTION

FOR EVALUATION AND TREATMENT

MH 302 (Rev. 10/09) Front

Confidential Client/Patient Information

See California WIC Section 5328 and

HIPAA Privacy Rule 45 C.F.R. § 164.508

Welfare and Institutions Code (WIC), Section 5157, requires that each person when first detained for psychiatric evaluation be given certain specific information orally, and a record be kept of the advisement by the evaluating facility.

DETAINMENT ADVISEMENT

My name is (1)_______________________________

I am a (Peace Officer, etc.) with (Name of Agency).

You are not under criminal arrest, but I am taking you for examination by mental health professionals at(Name of Facility).

You will be told your rights by the mental health staff.

If taken into custody at his or her residence, the person shall also be told the following information in substantially the following form:

 

 

 

You may bring a few personal items with you which

 

(2)

Advisement Complete

Advisement Incomplete

will have to approve. You can make a phone call

 

 

 

 

and/or leave a note to tell your friends and/or family

Good Cause for Incomplete

(3)

where you have been taken.

 

 

 

 

 

 

 

 

Advisement Completed By

(4)

Position

(5)

Date

(6)

 

 

 

 

 

 

 

To

 

(7)

 

Application is hereby made for the admission of

(8)

 

Residing at

 

(9)

California, for 72-

hour treatment and evaluation pursuant to Section 5150, (adult) et seq. or Section 5585 et seq. (minor), of the WIC. If a minor, to the best of my knowledge, the legally responsible party appears to be / is: (Circle one) Parent; Legal Guardian; Juvenile Court as a WIC 300; Juvenile Court as a WIC 601/602; Conservator. If known, provide names, address and telephone number:

(10)

* * * * * * * * * *

The above person’s condition was called to my attention under the following circumstances: (see reverse side for definitions)

(11)

The following information has been established: (Please give sufficiently detailed information to support the belief that the person for whom evaluation and treatment is sought is in fact a danger to others, a danger to himself; herself and/or gravely disabled.)

(12)

(13)Based up on the above information it appears that there is probable cause to believe that said person is, as a result of mental

disorder:

 

 

 

A danger to himself/herself.

A danger to others.

Gravely disabled adult.

Gravely disabled minor.

Signature, title and badge number of peace officer, member of attending staff of evaluation facility or person

designated by county.

(14)

Date (15)

Time (16)

Phone

(17)

Name of Law Enforcement Agency or Evaluation Facility/Person

(18)

Address of Law Enforcement Agency or Evaluation Facility/Person

(19)

Weapon was confiscated and detained person notified of procedure for return of weapon pursuant to Section 8102 WIC.

(officer/unit & phone

NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY

NOTIFICATION OF PERSON’S RELEASE FROM AN EVALUATION AND TREATMENT FACILITY IS REQUESTED BY THE REFERRING PEACE OFFICER BECAUSE:

Person has been referred under circumstances in which criminal charges might be filed pursuant to Sections 5152.1 and 5152.2 WIC. Notify (officer/unit & telephone #)

Weapon was confiscated pursuant to Section 8102 WIC.

Notify (officer/unit & telephone #)

SEE REVERSE SIDE FOR INSTRUCTIONS

HOW TO COMPELTE 5150 APPLICATION FOR 72 HOUR DETENTION

Numbers 1-6: Detainment Advisement (See Appendix A for form)

The purpose of the detainment advisement is to inform the mentally ill individual that they have rights, are not under arrest and may take approved possessions with them to the hospital.

Print your name on this line (1).

The Advisement (located in the upper right hand corner of the form) should be read to clients. “Advisement complete” or “Advisement incomplete” should be checked (2).

If a patient is too ill to comprehend the verbal advisement, then do not read the Advisement, check

“Advisement incomplete” and document the reason in number (3).

If the Advisement is successfully read to the client, print your name in the section labeled “Advisement Completed By,” (4) print your position: Police Officer, Sheriff’s Deputy, etc…(5), and note the date (6).

The patient will receive a written advisement if, after being appropriately assessed at the hospital, he/she is

admitted.

Number 7-10: Application is Made To:

The name, address and phone number of the hospital or emergency room where the client will be transported is documented on this line (7).

Be as specific as possible in order to inform the ambulance driver or other applicable parties of the exact location of the receiving facility.

When indicating the name of the patient in the “Admission of” section (8), use the patient’s complete name.

Complete names are helpful in order to increase the likelihood the receiving facility can correctly identify the patient.

Completing the “Residing at” section (9) is critical. The address should be complete with zip code and phone number, if possible. Again, the receiving faculty may have only he 5150 form as identifying information, so the more complete the personal data, the better.

Circle the “Section 5150” or “Section 5585” to indicate which type of hold you are writing on the line below

(9).

The section below “Residing at” (10) is critical for the completion of the 5150/5585. You should put all the contact information available to you in this section. Neighbor’s names and phone numbers, parents, friends, case managers, conservator, landlord, treating clinician and so on. Hospital discharge planning often depends on the accuracy of this information.

Number 11: . . . Person’s Condition was called to my Attention

This section (11) identifies how the client came to your attention.

This information should be as complete as possible; it should include who initially contacted you, a short description of why the caller wanted assistance and what the client was doing to require an emergency assessment (initial complaint).

All descriptions are to be behavioral and not diagnostic.

Some examples of behavioral descriptions are:

“Called by resident to access a client that was running naked in the street,”

“Call from patient’s mother saying consumer was suicidal,”

“Called by school principal to assess student who expressed suicidal thoughts to school counselor,”

“Called by roommate because person threatened a neighbor,”

“Called by therapist at County mental health clinic that client known to them just called saying he was going to kill himself.”

In this section, do not put diagnostic description like “Patient is well known bi-polar disorder,” or “Patient suffering from major depression and ….”, or “Patient paranoid schizophrenic who is threatening people in the street.”

In this section do not put psychiatric jargon. For example: “Patient hallucinating and delusional,” “Patient having ideas of reference,” “Patient in manic state,” “Consumer psychotic.”

Number 12: “The following information has been established …”

This section (12) is the “heart” of the 5150/5585. The descriptions of the behaviors (not psychiatric diagnosis) that lead you to believe this patient can be held based on the three criteria (Danger to Self, Danger to Others or Gravely Disabled) is written in this section.

Behavioral descriptions mean writing what the patient DOES and SAYS, not what clinical term encompasses that behavior

Examples are:

“Patient pacing about the room yelling” instead of “Patient anxious & agitated.”

“Patient hearing voices that say …” rather than “Patient having auditory hallucinations.”

“Consumer tells me that the TV is speaking to him about things,” rather than, “Consumer experiencing thought insertion.”

“Patient seeing CIA agents about to attack him,” instead of “Patient experiencing visual hallucinations.”

“Patient feels he is married to Jennifer Lopez,” rather than “Patient delusional.”

“Patient says that he is sure someone is watching him from the vents in his apartment,” rather than “Patient paranoid schizophrenic with fixed delusional disorder.”

“Patient says she is going to kill herself by overdose because her boyfriend left her,” rather than “Patient has suicidal ideation and intent after failed romance.”

Quotes from the patient are highly desirable.

Behavioral descriptions from reliable sources are often very helpful. Be sure to identify the source. It is not

necessary to document name of someone who wishes to remain anonymous who is concerned about retaliation (neighbor’s full name, etc.).

Write enough to justify your decision to “hold” the patient.

May not write confidential and/or sensitive medical information in the narrative, such as “Patient has

AIDS.” The following is better: “patient has terminal/life threatening illness.”

May not list medications in the body of the 5150 (11, 12). If you must report medications, list them in section (10).

Do not diagnose the patient.

Do not predict future actions, just describe what you see and hear.

Keep in mind that a “hold” is meant to be written by a non-clinical person and is NOT a diagnostic assessment.

Numbers 13, 14 15, 16, 17, 18, 19: Criteria, Signatures, Timing and Medical ER Timing:

The following information refers to the final parts of the 5150/5585:

Check the box that correctly defines the criteria for the hold (13).

Sign the hold (14) and include your degree (LCSW, MD, Ph.D., LPT, MFT).

Date (15) and time (16) the hold (very important). This protects the patient’s rights and notifies the hospital when the patient should be evaluated for release.

Write the correct phone number (17) of your agency

Write the correct name (18) of your agency

Write the correct address (19) of your agency