Print Form Clear Form (12/21/09) CCCO 0110 Certificate of Examination IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION CERTIFICATE OF EXAMINATION Re:_____________________________________________________________________________________ (Print Name of Person Examined) I personally informed the above-named individual of the purpose of this examination and that he or she did not have to speak to me, and that any statements made might be related in court as to the individual’s clinical condition or need for services. Additionally, if this examination was for the purpose of determining that the above-named individual is mentally retarded and dangerous, I informed the individual of his or her right to speak with a relative, friend or attorney before the examination, and of his or her right to have an attorney appointed for him or her if he or she so desired. On __________________________, __________, at ______________ (Date) (year) a.m. p.m., I personally examined the (time) above-named individual. The examination was conducted at ___________________________________________________________. (Name of Location) Based on the foregoing examination it is my opinion that he or she is: (check all that apply) A person with mental illness who, because of his or her illness is reasonably expected to inflict serious physical harm on himself/herself or another in the near future; A person with mental illness who, because of his or her illness is reasonably expected to engage in *dangerous conduct which may include threatening behavior or conduct that places that person or another individual in reasonable expectation of harm; A person with mental illness who, because of his or her illness is unable to provide for his or her basic physical needs so as to guard himself or herself from serious harm, without the assistance of family or outside help. A person with mental illness who, because of the nature of his or her illness, is unable to understand his or her need for treatment and who, if not treated, is reasonably expected to suffer or continue to suffer mental deterioration or emotional deterioration, or both, to the point that the person is reasonably expected to engage in *dangerous conduct; A person who is mentally retarded and is reasonably expected to inflict serious physical harm upon himself or herself or others in the near future. I base my opinion on the following (including clinical observations, factual information): (Please print or type) I believe that the individual is subject to involuntary admission: ( Select “A” when examination was not ordered by the Court) A. on an emergency basis because he or she is in such a condition that immediate hospitalization is necessary for the protection of such person or others from physical harm; (Select B, C, or D, if the Respondent has been ordered by the Court to submit to an examination.; unless emergency hospitalization is necessary, then choose A.) B. C. inpatient hospitalization is the least restrictive facility appropriate; an alternative mental health facility such as admission to a residential facility; or an out-patient program; That facility/program is ____________________________________________; D. release into care and custody of a responsible person is appropriate for and available to the Respondent. Date: _________________________________ Signature: _______________________________________ Title: _________________________________ Printed Name: ____________________________________ (Check One) QUALIFIED EXAMINER PSYCHIATRIST PHYSICIAN CLINICAL PSYCHOLOGIST *Dangerous conduct means threatening behavior or conduct that places another individual in reasonable expectation of being harmed; or a person’s inability to provide, without the assistance of family or outside help, for his or her basic physical needs so as to guard himself or herself from serious harm. DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS