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Click ‘Get Form’ to open the Application, Certification and Medical Clearance for Emergency Admission of an Allegedly Mentally Ill Person in the editor.
Begin by filling out the personal information section, including the name of the allegedly mentally ill person and your details as the person completing the form.
In the section regarding observed behaviors, provide a detailed description of actions that led you to believe the individual poses a danger to themselves or others. Avoid using medical diagnoses.
Complete the medical clearance section by having a licensed physician examine the individual. Ensure they fill in their name, license number, and signature.
Finally, review all sections for accuracy before saving or printing your completed form. Make sure all required fields are filled out correctly.
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