My name is. I am a _____ (peace officer/mental health professional) _____. with _____ (name of agency) _____. You are not under criminal arrest, but I am taking you for an examination by mental health professionals at. _____ (name of facility) _____ You will be told your rights by the mental health staff. |
You may bring a few personal items with you, which I will have to approve. Please inform me if you need assistance turning off any appliance or water. You may make a phone call and leave a note to tell your friends or family where you have been taken.
My name is. |
My position here is. |
You are being placed into this psychiatric facility because it is our professional opinion that, as a result of a mental health disorder, you are likely to (check applicable): |
[] Harm yourself. [] Harm someone else. [] Be unable to take care of your own food, clothing, and housing needs. We believe this is true because |
(list of the facts upon which the allegation of dangerous or gravely disabled due to mental health disorder is based, including pertinent facts arising from the admission interview). |
You will be held for a period up to 72 hours. During the 72 hours you may also be transferred to another facility. You may request to be evaluated or treated at a facility of your choice. You may request to be evaluated or treated by a mental health professional of your choice. We cannot guarantee the facility or mental health professional you choose will be available, but we will honor your choice if we can. |
During these 72 hours you will be evaluated by the facility staff, and you may be given treatment, including medications. It is possible for you to be released before the end of the 72 hours. But if the staff decides that you need continued treatment you can be held for a longer period of time. If you are held longer than 72 hours, you have the right to a lawyer and a qualified interpreter and a hearing before a judge. If you are unable to pay for the lawyer, then one will be provided to you free of charge. |
If you have questions about your legal rights, you may contact the county Patients' Rights Advocate at _____ (phone number for the county Patients' Rights Advocacy office) _____. Your 72-hour period began _____ (date/time) _____. |
Ca. Welf. and Inst. Code § 5150