N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 1
ADMISSION FORMS
INDEX
Form 19--D.M.H. Order of Transfer
Form 41--D.M.H. Application for Voluntary or Minor Voluntary Admission to a School
Form 42--D.M.H. Notice of Status and Rights--Voluntary or Minor Voluntary Admission
Form 42a--D.M.H. Notice of Status and Rights--Conversion to Voluntary or Minor Voluntary Status
Form 43--D.M.H. Application for Non-objecting or Involuntary Admission to a School
Form 43a--D.M.H. Certificate of Examination by Examining Physician or Certified Psychologist
Form 44--D.M.H. Notice of Status and Rights--Involuntary Admission
Form 44a--D.M.H. Notice of Status and Rights--Conversion to Involuntary Status
Form 44b--D.M.H. Notice of Status and Rights--Non-objecting Admission
Form 45--D.M.H. Application for Court Authorization to Retain Resident
Form 45a--D.M.H. Notice of Application for Court Authorization to Retain Resident
Form 451--D.M.H. Application for Voluntary or Minor Voluntary Admission to an Alcoholism Facility
Form 452--D.M.H. Notice of Status and Rights--Voluntary or Minor Voluntary Admission (Alcoholism)
Form 452a--D.M.H. Notice of Status and Rights--Conversion to Voluntary or Minor Voluntary Status (Alcoholism)
Form 453--D.M.H. Application for Involuntary Admission to an Alcoholism Facility
Form 453a--D.M.H. Medical Certificate of Alcoholism
Form 454--D.M.H. Notice of Status and Rights--Involuntary Admission (Alcoholism)
Form 454a--D.M.H. Notice of Status and Rights--Conversion to Involuntary Status (Alcoholism)
Form 457--D.M.H. Order of Commitment for Psychiatric Examination under Family Court Act
Form 459--D.M.H. Identifying Data Sheet
Form 460--D.M.H. Notice of Status and Rights--Voluntary or Minor Voluntary Admission
Form 460a--D.M.H. Notice of Status and Rights--Conversion to Voluntary or Minor Voluntary Status
Form 461--D.M.H. Notice of Status and Rights--Involuntary Admission
Form 461a--D.M.H. Notice of Status and Rights--Conversion to Involuntary Status
Form 464--D.M.H. Notice of Hearing
Form 465--D.M.H. Civil Order for Hospitalization
Form 467--D.M.H. Request for Court Hearing
Form 471--D.M.H. Application for Admission of Patient
Form 471a--D.M.H. Certificate of Examining Physician (Mental Illness)
Form 471b--D.M.H. Certificate of Examination by Director of Community Services or his Designee
Form 471c--D.M.H. Examination for 72 Hour Conversion to Two Physician Status
Form 472--D.M.H. Voluntary Request for Hospitalization
Form 474--D.M.H. Record of Emergency Admission
Form 474a--D.M.H. Notice of Status and Rights--Emergency Admission
Form 476--D.M.H. Form for the Court Commitment of Certain Dangerously Mentally Disabled Patients
Form 476a--D.M.H. Certificate of Examining Physician
Form 476b--D.M.H. Notice of Petition for Order of Commitment
FORM 19--D.M.H.
FORM 19 DMH (5/73)
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
ORDER OF TRANSFER
(Pursuant to Section 29.11 of the Mental Hygiene Law)
Albany, N.Y. ____________, 19________,
A written request to this Department having been made for the transfer of ____________
____________
a patient at____________,
and the reasons for such transfer being satisfactory, and the Mental Health Information Service having been given notice of the proposed transfer, it is hereby ordered that the director of said facility discharge said patient for transfer to
____________,
and that the director of the latter facility receive said patient for treatment upon the presentation of this original order, together with the original admission paper and case record.
BY THE COMMISSIONER:
______________
(SIGNATURE)
______________
(PRINT NAME)
______________
(TITLE)
FORM 45 DMH (1/73) PAGE 2
CERTIFICATION OF SERVICE OF NOTICE
I am the Director of ________, a school for the mentally retarded, and hereby certify that, pursuant to Article 33 of the Mental Hygiene Law, and in accordance with the Rules and Regulations of the Commissioner of Mental Hygiene, I have caused copies of the attached "Notice of Application for Court Authorization to Retain Resident" to be served personally, on ________, 19 ________, on the resident identified in the Application; and to be served by mail, posted on ________,19 ________, on the Mental Health Information Service and all of the persons whose names appear at the foot of said notice, the foregoing being all of those entitled to receive such notice under law. At least five days, excluding Sundays and holidays, have elapsed from the time of the last service thus made and
(Strike Inapplicable Section Below)
NO HEARING REQUESTED
No request by or on behalf of said resident for a hearing on the foregoing application has been received by the undersigned.
HEARING REQUESTED
A request for a hearing has been made by or on behalf of the above named resident (copy attached). A record of said resident as required by law is attached hereto.
DATE: ________, 19________
______________
SIGNATURE
______________
(PRINT NAME TO BE SIGNED)
FORM 476--D.M.H.
FORM 476 DMH (1/73) PAGE 1
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORM FOR THE COURT COMMITMENT OF
CERTAIN DANGEROUSLY MENTALLY DISABLED PATIENTS
SECTION 1
ORDER OF COMMISSIONER OF MENTAL HYGIENE
To Dr.____________, Director of
___________
___________
(ADDRESS)
Information having been presented to me showing that
an involuntary patient at
mentally disabled that his presence in a Department of Mental Hygiene facility is dangerous to the safety of other patients therein, the officers or employees thereof, or to the community, and full consideration having been given thereto, you are hereby directed to make application to the Supreme Court or County Court within the County wherein your facility is located, or to the Supreme Court in the Judicial District wherein such county is located, for an order directing the examination of the said patient pursuant to Section 29.13 of the Mental Hygiene Law.
____________
________COMMISSIONER AND DULY AUTHORIZED DESIGNEE OF THE COMMISSIONER OF MENTAL HYGIENE
I
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORMS FOR THE COURT COMMITMENT OF CERTAIN DANGEROUSLY MENTALLY DISABLED PATIENTS PRESCRIBED BY THE DEPARTMENT OF MENTAL HYGIENE,
PURSUANT TO THE PROVISIONS OF SECTION 29.13 OF THE MENTAL HYGIENE LAW.
INSTRUCTIONS
This booklet contains the forms which are to be used in proceedings under Section 29.13 of the Mental Hygiene Law. This section of the law provides for court commitment to institutions in the Department of Correctional Services of mentally disabled persons who are involuntary patients at facilities in the Department of Mental Hygiene and who have become so dangerously mentally disabled that their presence in Mental Hygiene facilities is dangerous to the Safety of other patients, the officers or employees thereof or to the community.
LIST OF FORMS
The following are the forms contained in this booklet:
Form 476 DMH:
Section 1. Order of Commissioner of Mental Hygiene (printed separately for completion in Albany only).
Section 2. Notice of Application for Order of Examination
Section 3. Application for Order of Examination
Section 4. Affidavit of Service of Notice (of Application for Order of Examination)
Section 5. Order of Examination
Form 476A DMH: Certificate of Examining Physician (2 copies)
Form 476B DMH:
Section 1. Notice of Petition for Order of Commitment
Section 2. Petition
Section 3. Affidavit of Service (of Notice of Petition and the Petition)
Section 4. Order of Hearing
Section 5. Affidavit of Service of Order of Hearing
Section 6. Decision of Court After Hearing
Section 7. Court Order of Commitment or Denial
PROCEDURE
1. The Director of the Mental Hygiene facility first obtained the Order of the Commissioner of Mental Hygiene or his duly authorized designee. This Order can be given verbally over the phone, but must then be followed up by a written Order of the Commissioner of Mental Hygiene which becomes Section 1 of form 476 DMH. See page 1A of Form 476 DMH for more detailed instructions.
2. The Director prepares the "Notice of Application for Order of Examination" (Section 2) and the "Application for Order of Examination" (Section 3) on Form 476 DMH.
3. Exact photocopies of Section 2 and Section 3 are prepared. One copy of each Section is served personally on the patient. Another copy of each Section is served either personally or by registered mail upon the Mental Health Information Service. The person effecting the service of this notice then completes the "Affidavit of Service of Notice (of Application for Order of Examination) " (Section 4).
4. The Director attaches the written Order of the Commissioner of Mental Hygiene (Form 476 DMH, Page 1) on top of page 1A of Form 476 DMH. He then submits the complete application, together with two blank copies of Form 476A DMH, "Certificate of Examining Physician," to the appropriate court or judge. The judge, upon due consideration signs the "Order of Examination" (Section 5) designating two examining physicians. These examining physicians cannot be connected with the facility where the patient is confined.
II
5. The Court sends copies of the "Order of Examination" (Section 5, Form 476 DMH) plus a blank Form 476A DMH to each of the designated examining physicians. The examining physicians conduct their examinations of the patient and each prepares a "Certificate of Examining Physician" (Form 476A DMH) . The completed certificates are then delivered to the Director of the Mental Hygiene Facility for presentation to the Court along with his Petition.
6. The Director prepares the "Notice of Petition for Order of Commitment" (Section 1) and the "Petition" (Section 2) on Form 476B DMH.
7. Exact photocopies of Section 1 and Section 2 of Form 476B DMH are prepared. One copy of each Section is served personally on the patient. Other copies of both Sections are served either personally or by registered mail upon the Mental Health Information Service and upon either the wife, husband, father or mother or other nearest relative, if there be any in the State, and if there be any such relative, then upon any known friend of the patient. Service of this notice must be made at least five days prior to the date on which the Petition is to be presented to the court when service is made personally. If Service is by mail, three days must be added, making a total of 8 days required so the minimum period of notice. The person effecting the service of this notice then completes the "Affidavit of Service (of Notice of Petition and The Petition) " (Section 3).
8. After the expiration of the minimum period of notice as indicated above the Director submits the Petition and the Certificates of Examination to the court which ordered the examination. Since a hearing is now mandated by Law, the judge will prepare the "Order of Hearing" (Section 4), setting a date for the hearing not more than five days from the date of which the Petition is received by the court. At this time the judge will also appoint counsel to represent the patient at the hearing, if the patient has not previously obtained counsel on his own behalf.
9. Copies of the "Order of Hearing" (Section 4) must be prepared by the court and served on the parties who are designated in the Order as having to he served. A copy of this Order must he served personally on the patient and either personally or by registered mail on the Mental Health Information Service and the other designated persons. The person effecting service of the Order then completes the "Affidavit of Service of Order of Hearing" (Section 5).
10. After the hearing is held, the judge completes the "Decision of Court After Hearing" (Section 6) and the "Court Order of Commissioner or Denial" (Section 7).
11. If an immediate commitment to an institution in the Department of Correctional Services is needed pending outcome of this proceeding, application must be made to the judge on Form 476C DMH. This form (not included in this booklet) contains the petition of the Director and the affidavit of two examining physicians that the Director is not able to properly care for the allegedly dangerous patient at the facility where he is confined and that the patient is in need of immediate treatment. The examining Physicians for this purpose may be connected with the Mental Hygiene facility where the patient is confined. The form also contains the "Order of Forthwith Commitment."
III
PROVISIONS OF THE MENTAL HYGIENE LAW
Section 29.13 -- Proceedings for commitment of certain dangerous patients to institutions in the Department of Correction.
(a) As used in this section:
"patient" means a person admitted to a hospital or school in the department and retained therein on an involuntary basis pursuant to the provisions of this chapter.
"dangerous" means that a patient has committed or is liable to commit an act or acts which, if committed by a person criminally responsible for his conduct, would constitute homicide or felonious assault or is so dangerously mentally disabled that his presence in the department hospital or school is dangerous to the safety of other patients therein, to the officers or employees thereof, or to the community.
(b) The director of any hospital or school in the department may, upon order of the commissioner and after notice to the patient and the mental health information service, make application to the supreme court or county court within the county wherein such facility is located or to the supreme court in the judicial district wherein such county is located for an order of examination of an allegedly dangerous patient at such hospital or school. Such examination shall be conducted by two examining physicians, other than a physician connected with such hospital or school, to be designated by the court. Each physician, if satisfied, after a personal examination, that such patient is dangerous shall make a certificate to that effect.
(c) Upon such certificate of the examining physicians being so made, it shall be delivered to the director of the facility, who shall forthwith apply by petition to the court which ordered the examination, annexing such certificate to his petition, for an order committing such allegedly dangerous patient to an appropriate institution in the state department of correction. Written notice of such application, together with a copy of the petition, shall be served upon the allegedly dangerous patient personally, upon the mental health information service, and upon either the wife husband, father, mother, or nearest relative of such patient or, if there be no such relative within the state, upon any known friend of the patient. Such service shall be made at least five days in advance of the return date if service is effected personally or at least eight days in advance of the return date if service is effected by mail. If there be no such known relative or friend within the state, the giving of such notice shall be dispensed with, but in such care the petition and the order of commitment shall recite the reasons why service of such notice on a relative or friend of the allegedly dangerous patient was dispensed with.
(d) The court to which such application for the commitment of the allegedly dangerous patient has been made shall order a hearing. The date of such hearing shall be fixed at a time not more than five days from the date on which the application is received by the court. Such allegedly dangerous patient shall be represented by counsel in any such proceedings. The court shall hear the testimony introduced by the parties and shall examine such allegedly dangerous patient, if deemed advisable in or out of court, and render a decision in writing as to such patient's dangerousness. If it be determined that such patient is dangerous, the court shall forthwith issue its order committing such patient to an appropriate institution in the state department of correction for a period not to exceed six months from the date of such order. The director of the department facility shall thereupon cause such dangerous patient to be delivered to such institution in the department of correction and such dangerous patient shall be received into such institution and retained there until the expiration of the period of authorized retention provided for in the order of commitment or in any further order issued pursuant to this section. If such patient is no longer dangerous to safety, he shall be released prior to the expiration of any such period in the manner provided in sectionsection four hundred nine of the correction law or, if he is in need of continued care and treatment, he may be transferred to an in-patient hospital or school in the department of mental hygiene upon the order of the commissioner of mental hygiene. If the director of the facility
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in the department of mental hygiene shall deem that the condition of a patient so transferred is in need of continued retention, he shall apply to the supreme court or county court prior to the expiration of sixty days from the date of such transfer for an order authorizing continued retention in accordance with the provisions of this chapter relating to application for court authorization for retention of such a mentally ill or mentally retarded patient.
(e) If the director or person in charge of the institution in the correction department to which the dangerous patient has been committed pursuant to this section shall deem that the condition of such patient requires his further retention in such institution because of his dangerousness, he shall apply during the period of retention authorized by the last order of the court for an order authorizing the continued retention of such patient. The provisions of this chapter which apply to applications for orders authorizing the retention or further continued retention of a patient in a hospital or a school shall apply except that, in addition to the need for retention for mental illness or mental retardation, the question of the continued dangerousness of such patient shall be determined. If it be determined that the patient is no longer in need of retention or is no longer dangerous, the court may order the discharge of the patient or it may order the transfer of the patient to a facility in the department.
(f) Any court order of commitment or court order authorizing retention or continued retention pursuant to this section is subject to review in accordance with section 31.35 of this chapter in the case of a mentally ill person or in accordance with section 33.35 of this chapter in the case of a mentally retarded person.
(g) Orders for commitment or authorizing retention pursuant to this section shall not be deemed as, or received in any court in evidence of, the commission of a crime by the patient so committed nor shall such commitment be deemed or considered as punishment for a crime.
(h) The costs necessarily incurred, under this section, in determining the dangerousness of such patient, including fees of the examiners, fees of the medical witnesses, and any other necessary expenses allowed by the court, shall be a charge upon the county from which such person was originally certified, but in the city of New York, the court shall order such costs audited and allowed by the comptroller from the court fund and charged to the proper county within the said city.
(i) During the pendency of such proceeding the court may forthwith order the commitment of such allegedly dangerous patient to an appropriate institution in the department of correction upon petition and the affidavit of two examining physicians that the director of the hospital or school is not able to properly care for such patient at the facility where he is confined and that such patient is in need of immediate treatment.
(j) The notices provided for herein may be served by registered mail on all persons required to be served other than the allegedly dangerous patient.
FORM 476 DMH (1/73) PAGE 1A
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORMS FOR THE COURT COMMITMENT OF
CERTAIN DANGEROUSLY MENTALLY DISABLED PATIENTS
INSTRUCTIONS
Upon determination by the Director of a Department of Mental Hygiene facility that a patient in his facility is so dangerous that he should be committed to an institution in the Department of Correctional Services, the Director may immediately proceed to complete Sections Two and Three of this form, upon the verbal order of the Commissioner of Mental Hygiene or his duly authorized designee.
Exact copies of those sections may be served upon the patient and the Mental Health Information Service prior to receipt of the Commissioner's written order (Section 1). However, before this application is submitted to the Court, the Commissioner's written order on Form 476 DMH, Page 1, must be received and attached to the face of this form, and the Affidavit of Service of Notice (Section 4) must be completed.
This form, with the Commissioner's written order attached, must be submitted to the appropriate Court along with the attached two blank copies of Form 476A DMH, "Certificate of Examining Physician". Detach and save the attached copy of Form 476B DMH for later submission to the Court along with the completed Certificates of Examination.
If a Forthwith Commitment is desired, Form 476C DMH must be completed by the Director and two physicians on the staff of the Mental Hygiene facility, and may be submitted to the Court along with the Forms 476 and 476A. Form 476C DMH cannot be submitted to the Court prior to receipt of the written Order of the Commissioner and the submission to the Court of the completed Form 476 DMH.
FORM 476B DMH (1/73) PAGE 3
SECTION 3
AFFIDAVIT OF SERVICE (OF NOTICE OF PETITION AND THE PETITION)
STATE OF NEW YORK
COUNTY OF________
________ being duly sworn, says that he is over 18 years of age, and that on the ________ day of ________, 19________, at ________he served the foregoing Notice of Petition, and Petition upon the patient,
(PATIENT) and upon
(NAME OF RELATIVE OR FRIEND)
the
(STATE RELATIONSHIP) of
(PATIENT)
and upon the Mental Health Information Service by delivering a true copy of said Notice and Petition personally to the said patient and ________, and serving the same by registered mail upon the Mental Health Information Service and ________. He further says that be knew the persons served, as aforesaid, to be
disabled patient, and
(NAME OF RELATIVE OR FRIEND) to be
the
(STATE RELATIONSHIP) of the person mentioned and
described in the said application.
Sworn to before this ________
day of ________, 19________
(OFFICIAL TITLE)
(SIGNATURE OF SERVER OF NOTICE)
FORM 476B DMH (1/73) PAGE 5
SECTION 5
AFFIDAVIT OF SERVICE OF ORDER OF HEARING
STATE OF NEW YORK
COUNTY OF________
________, being duly sworn, says that he is ever 18 years of age, and that on the ________ day
if ________ 19________, at ________ he served the foregoing ORDER OF HEARING upon the
patient,
and ________, the persons directed to be served in the said Order of Hearing, and upon the Mental Health Information Service by delivering a true copy of said ORDER personally
to
(PATIENT) and ________, and by serving the same by registered mail
upon the Mental Health Information Service and ________. He further says that he knew the persons specified in the said Order.
Sworn to befor me this ________
day of ________, 19________
(OFFICIAL TITLE)
(SIGNATURE OF SERVER OF NOTICE)
FORM 476B DMH (1/73)
ORDERED, that the sum of $ ________ be and the same is hereby allowed and awarded to
________, M.D., and the sum of $ ________ be and the same is hereby allowed and awarded to
________, M.D., for their fees and expenses as examining physicians, and it appearing that the
said patient, ________, was admitted to
(MENTAL HYGIENE FACILITY
from ________ County,
it is further:
ORDERED, that the fees and costs aforesaid be audited and allowed by:
(Select one of the following:
(a) ________ County
OR
(b) the Comptroller of the City of New York from the court fund and charged to ________ County within the said City.
DATED ________, 19________ (Signature) ________
____________
(PRINT NAME TO BE SIGNED)
Justice or Judge of
____________
(COURT)
N.Y. Comp. Codes R. & Regs. tit. 14, Appendices, app 1
Statutory authority: Mental Hygiene Law, §29.01