(Revised 0/01/) Kaweah Delta Mental Health Hospital 1100 S . Ak e rs Road Visali a , C A 9 32 77 55 9 624 3300 NOTICE OF CERTIFICATION FOR INTENSIVE TREATMENT A division of Kawea h Del ta H ealth Ca re District PURSUANT TO WELFARE AND INSTITUTIONS CODE 247 5250/5250.17 (strike out inapplicable section) The authorized agency providing evaluation services n the County of Tulare has evaluated the condition of: Name: Age: Sex: Marital Status: Address: We, the undersigned, allege that the above-named person is, as a result of a mental disorder or impairment by chronic alcoholism (strike out all inapplicable classifications): 1. A danger to others, 2. A danger to himself or herself, or 3. Gravely disabled as defined in Welfare and Institutions Code 247 5250(d)(1)-(2), 5008(h)(1)(A). The sp ecific facts which f or m (he basis for our opinion that t he above - named person meets one or more of the classifications indicated above are as follows (certifying person s to d etail facts) : The above-named person has been informed of this evaluation, and has been advised of but has not been able or willing to accept referral to, the following services: Therefore we certify the above - named person to rece ive intensive treatment related to the mental disorder or impairment by chronic a lcohol ism beginning t h is day of ( mont h) , 20 , in the intensive treatment facility named: KAWEAH DELTA MENTAL HEALTH HOSPITAL 1100 South Akers Road Visalia, CA 93277 We hereby stale that we delivered a copy of this notice this day to the above - named person and that we informed him or her tha t a certification review hearing will be held within four days of the date on whi ch the person is certified for a period of intensive treatment and tha t an attorney or advocate will visit him or her to provide assistance in preparing for the hearing or to ans wer questions regarding his or her commitment or to provide other assistance. The court has been not ified of this certification date. Also, on this day the above -named person has been informed of his/her legal right to a judicial review by Habeas Corpus, and the term "Habeas Corpus" has been explained to him/her, and that he/she has been informed of his/her right to counsel, including court -appointed counsel pursuant to Welfare and Institutions Code 247 5276. Date : Time a.m./ p. m. Signature: Signature: (p h ysicia n /s t aff mem ber of facility) (representing intensive t reatm ent faci lity ) Signature : (co unter signature ) NOTICE OF CERTIFICATION FOR INTENSIVE TREATMENT COPIES; Court 226 Patient 226 Hearing Officer 226 PRA 226 Chart EXHIBIT 3 5 155 American LegalNet, Inc.