APPLICATION FOR 72 - HOUR DETENTION FOR EVALUATION AND TREATMENT Confidential Client/Patient information See California W & / Code Section 5328 W & I Code, Section 5157, requires that each person when first detained for psychiatric evaluation be given certain specific information orally, and a record be kept of the advisement by the evaluating facility. DETAINMENT ADVISEMENT My name is . I am a (Peace Officer, etc.) with (Name of Agency). You are not under criminal arrest, but I am taking you for examination by mental health professionals at Kaweah Delta District Hospital/Kaweah Delta Mental Health Hospital. You will be told your rights by the mental health staff. It taken into custody at his or her residence, the person shall also be told the following information, in substantially me following form: You may bring a few personal items with you which I wilt have to approve. You can make a phone call and/or leave a note to tell your friends and/or family where you have been ken. Advisement Complete Advisement Incomplete Good Cause for Incomplete Advisement: Advisement Completed By: Position. Da t e: To Kaweah Delt a District Hospi tal/ Kaw e ah Delta Mental Health Hospital: Application Is hereby made for the admission o f , residing at . California, for 72-hour treatment and evaluation pursuant to Welfare and Institutions Code 2475150 (adult) et seq. or 2475585 (minor) et seq. If a minor or conservatee, to the best of my knowledge, the legally responsible party appears to be: Parent Legal Guardian Juvenile Court W I C 247 30 0 Juvenile Co urt W I C 247247 601/602 Conservator Provid e Na m e/Addr e ss/Te l ep h one number: The Personal Property of t he person apprehended, described generally as , was preserved and safeguarded by (name of person taking patient into custody, responsible relative, guardian or conserva t o r ) . Property is now located at . The above person's condition was called to my attention under the following circumstances: The following informationhas been established; ( please give sufficiently detaile d In formation to support the probable caus e finding that the person for whom evaluation and treatment is sought is in fact a danger to others, a danger to hlmself/herself and/or gravity disabled): Based on the above information it appe ars that there is probable cause to be li eve that said person is, as a result of mental d is order: danger to himself/herself danger to others Gravely disabled adult Gravely disabled minor S i gna t ure, title, and ba dge number of peace officer, member or attending staff of evaluation facility or person designated by county Date: Telephone: Time: Name of Law Enforcement Agency or KDMHH person: Fax/Address of Law Enforcement Agency: A Firearm/Dangerous Weapon was confiscated. Detained person notified of procedure for return of weapon pursuant to WIC 2478102. Describe: Officer /I .D .#: Unit: Telephone Numb e r: Notification to be provided to Law Enforcement Agency, pursuant to WIC 5152.1, by facsimile is requested as the patient is referred under circumstances in w hich criminal charges migh t be fi led. www.FormsWorkFlow.com