____________________________________________ |
___________________________________________ |
Print Name Here (not required if electronically signed) |
Print Name Here (Not required if electronically signed) |
CSB report to court and recommendations for the individual’s placement, care and treatment pursuant to 16.1-340.4 (Minor) or 37.2-816 (Adult)
Name of Individual: __________________________________________ |
Date: _____________ Time: _____________am pm |
No further treatment required.
Has or does not have sufficient capacity to accept treatment (N/A for minors under age 14 except for Outpatient treatment) Is or is not willing to be treated voluntarily (* not applicable under Virginia Code19.2-169.6)
Voluntary community treatment at the CSB (specify) _______________________________________________________________
Or other (specify) __________________________________________________________________________________
Voluntary admission to a crisis stabilization program (specify) _________________________________________________________
Adult: Voluntary inpatient treatment because individual requires hospitalization and has indicated that he/she will agree to a voluntary period of treatment up to 72 hours and will give the facility 48 hours notice to leave in lieu of involuntary admission.
Minor: Voluntary inpatient treatment of minor younger than 14 or non-objecting minor 14 years of age or older.
Minor: Parental admission of an objecting minor 14 years of age or older pursuant to 16.1-339.
Minor 16.1-340.4 Under age 14 Age 14 or Older
Parent or guardian is or is not willing to consent to voluntary admission (for inpatient treatment only)
Because of Mental Illness meets the criteria for involuntary admission or mandatory outpatient treatment as follows:
The minor presents a serious danger to self or others to the extent that severe or irremediable injury is likely to result, as evidence by recent acts or threats or:
Is experiencing a serious deterioration of his ability to care for himself in a developmentally age appropriate manner, evidenced by: delusional thinking or significant
impairment of functioning in: hydration nutrition self protection self control. The minor is in need of compulsory treatment for a mental illness and is reasonably likely to benefit from the proposed treatment. Is the parent or guardian with whom the minor resides willing to approve any proposed commitment?
Yes No Unavailable
If no, is such treatment necessary to protect the minor’s life, health, safety or normal development? Yes No
Therefore the CSB recommends:
A. Involuntary admission and inpatient treatment, as there are no less restrictive alternatives to inpatient treatment.
Alternative transportation
B. Mandatory outpatient treatment (16.1-345.2) not to exceed 90 days because less restrictive alternatives to involuntary inpatient treatment that would offer an opportunity for improvement of his condition have been investigated and determined to be appropriate; and providers of the services have agreed to deliver the services: The minor, if 14 years of age or older, and his parents or guardians have sufficient capacity to understand the stipulations of the minor’s treatment, have expressed an interest in the minor’s living in the community and have agreed to abide by the minor’s treatment plan, and are deemed to have the capacity to comply with the treatment plan and understand and adhere to conditions and requirements of the treatment and services; and the ordered treatment can be delivered on an outpatient basis by the Community Services Board or a designated provider(s): specify:______________________________________________
C. Do the best interests of the minor require an order directing either or both of the minor’s parents or guardian to comply with reasonable conditions relating to the minor’s treatment? Yes No
Adult 37.2-816
Because of Mental Illness meets the criteria for involuntary admission or mandatory outpatient treatment (* not applicable under Virginia Code19.2-
169-6)as follows:
There is a substantial likelihood of serious physical harm to self or others in the near future as a result of mental illness as evidenced by recent behavior causing, attempting or threatening harm and other relevant information, if any, or
There is substantial likelihood that, as a result of mental illness, in the near future he/she will suffer serious harm due to lack of capacity:
to protect him/herself from harm or
to provide for his/her basic human needs (* not applicable under Virginia Code19.2-169.6).
Therefore the CSB recommends:
A. Involuntary admission and inpatient treatment as there are no less restrictive alternatives to inpatient treatment.
Alternative transportation
B. Mandatory outpatient treatment (37.2-817 (D) )because less restrictive alternatives to involuntary inpatient treatment that would offer an opportunity for improvement of his/her condition have been investigated and are deemed to be appropriate; and the person has agreed to abide by his/her treatment plan, and has the ability to do so. The recommended treatment is actually available on an outpatient basis by the CSB or designated provider(s) specify:
_____________________________________.
C. Physician discharge to mandatory outpatient treatment following inpatient admission pursuant to 37.2-817 (C1) and (C2). The person has a history of lack of
compliance with treatment for mental illness that at least twice within the past 36 months has resulted in the person being subject to an order for involuntary admission in view of the person’s treatment history and current behavior, the person is in need of mandatory outpatient treatment following inpatient treatment in order to prevent relapse or deterioration of his condition that would be likely to result in the person meeting the criteria for involuntary inpatient treatment; as a result of
mental illness, the person is unlikely to voluntarily participate in outpatient treatment unless the court enters an order authorizing discharge to mandatory outpatient treatment, and the person is likely to benefit from mandatory outpatient treatment.
