Peace Officer Mental Health Professional Application For Examination
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Peace Officer Mental Health Professional Application For Examination Form. This is a Alaska form and can be use in Mental Commitment Statewide.
Loading PDF...
Tags: Peace Officer Mental Health Professional Application For Examination, MC-105, Alaska Statewide, Mental Commitment
PEACE OFFICER/MENTAL HEALTH PROFESSIONAL
APPLICATION FOR EXAMINATION (AS 47.30.705)
Name of Potential Patient:
Date and Time:
Age:
Sex:
Marital
Status:
Race:
I hereby certify that probable cause exists under AS 47.30.705 to believe that the
above-named individual is mentally ill and is:
gravely disabled
likely to cause serious harm to
self
others
of such immediate nature that considerations of safety do not allow initiation of
involuntary commitment procedures under AS 47.30.700.
Pertinent Information:
I am a:
peace officer.
psychiatrist / physician currently licensed to practice in the state of Alaska
or employed by the federal government.
clinical psychologist licensed by the state Board of Psychologist and
Psychological Associate Examiners.
Signature of Peace Officer or
Mental Health Professional
Print Name
Daytime Telephone Number
Mailing Address
City
State
Zip
NOTE: Pursuant to AS 47.30.705, any police officer or mental health professional
requesting an emergency evaluation must complete an application for examination of
the person in custody and be interviewed by a mental health professional at the
evaluating facility.
MC-105 (1/07)(st.3)
PEACE OFFICER/MENTAL HEALTH PROFESSIONAL
APPLICATION FOR EXAMINATION
AS 47.30.705
American LegalNet, Inc.
www.FormsWorkflow.com
