5250 form-2026

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The document is a certification notice from the California Department of Health Care Services regarding the intensive treatment of individuals with mental disorders or chronic alcoholism. It outlines the legal basis for a 14-day or 30-day hold, details the patient's information, and states the reasons for certification, including potential danger to self or others. It also informs the patient about their rights, including the right to a judicial review hearing.

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Click ‘Get Form’ to open the 5250 form in the editor.
Begin by filling in the 'County of' field, specifying the authorized agency providing intensive treatment.
Complete the personal information section, including the patient's name, address, marital status, date of birth, and sex.
Indicate any applicable classifications by checking the boxes for 'A danger to others', 'A danger to himself or herself', or 'Gravely disabled'.
Provide specific facts that support your opinion regarding the patient's condition in the designated area.
Fill in the date when intensive treatment begins and specify the name of the treatment facility.
Ensure all signatures are completed along with their respective dates at the bottom of the form.

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