STATE OF NORTH CAROLINA Department of Health and ... 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling in the 'County' and 'Client Record #' fields at the top of the form. Ensure accuracy as this information is crucial for identification.
3. Complete the respondent's personal details, including their name, date of birth (DOB), age, address, city, state, and contact information. This section is vital for establishing the identity of the individual being evaluated.
4. In the 'Examination Information' section, indicate the date and time of the examination. Select whether it was conducted in person and provide details about the facility if applicable.
5. Proceed to Section I – Criteria for Commitment. Check all relevant boxes that apply to the respondent’s condition based on your assessment.
6. In Section II – Description of Findings, provide a clear description of your findings related to each criterion checked in Section I. This should include impressions or diagnoses.
7. Finally, complete Section III – Recommendation for Disposition by selecting appropriate options regarding commitment or treatment recommendations.

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