AOC-703A Doc. Code: CIT Rev. 07-04 Page 1 of 3 Commonwealth of Kentucky CERTIFICATION OF QUALIFIED Court of Justice www.kycourts.net HEALTH PROFESSIONAL KRS 222 INVOLUNTARY TREATMENT (ALCOHOL/DRUG ABUSE) Case No.______________________ District Court_________________________ County_______________________ IN THE INTEREST OF: RESPONDENT___________________________________________________________________________________________ 1. Comes the Affiant, ________________________________________________________________________, and states that he/she is a Qualified Health Professional as defined in KRS 222, and he/she is, [ ] A Qualified Mental Health Professional as defined in KRS 202A.011; and/or [ ] An Alcohol and Drug Counselor certified under KRS Chapter 309; and/or [ ] A Physician, licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the performance of official duties. 2. Affiant further states that he/she examined the above-named Respondent and based on that examination, in his/her professional opinion, the Respondent [ [ [ [ 3. ] ] ] ] does, does, does, can, [ [ [ [ ] ] ] ] does not suffer from alcohol and other drug abuse, does not present a danger to self, family or others, or there does not exist a substantial likelihood of such a threat in the near future; and cannot reasonably benefit from treatment. The facts that support Affiant's belief that Respondent does suffer from alcohol and other drug abuse: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 4. The facts that support Affiant's belief that Respondent is a danger or threat of danger to self, family or others, or that there exists a substantial likelihood of such a threat in the near future: ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 5. Diagnostic impressions:___________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com AOC-703A Rev. 07-04 Page 2 of 3 6. Doc. Code: CIT Other factors contributing to need for treatment:________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 7. Goal of treatment and recommendation for treatment:___________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 8. Date examination was performed:__________________________ Further, Affiant sayeth naught. ____________________________ _______________________________________ Date Signature of QHP _______________________________________ Name of QHP (Please Print) _______________________________________ Title of QHP _______________________________________ Name of Treatment Facility of QHP SUBSCRIBED and SWORN TO before me on this _______ day of _______________________________, 2________. My Commission expires: ______________________________ ____________________________________________ Name/Title ____________________________________________ County, Kentucky NOTE: A separate Certification of Qualified Health Professional (AOC 703A) must be filed with the Court by each of the two (2) QHPs named in the Hearing, Examination and Appointment of Counsel Notice and Order (AOC-701A) not later than twenty-four (24) hours prior to the hearing date set out in AOC-701A, unless another hearing date is ordered by the Court. See page 3 for more information on Qualified Health Professionals. Petitioner is responsible for all costs of examination. American LegalNet, Inc. www.USCourtForms.com AOC-703A Doc Code: CIT Rev. 07-04 Page 3 of 3 CERTIFICATION Note: This case requires a Certification to be completed and filed by each of two “Qualified Health Professionals.” At least one certification must be completed by a licensed physician. Criteria for each professional is listed below. "Qualified health professional" has the same meaning as qualified mental health professional in KRS 202A.011, except that it also includes an alcohol and drug counselor certified under KRS Chapter 309. “Qualified mental health professional” under KRS 202A.011(12) means: a. A physician licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the performance of official duties. b. A psychiatrist licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the practice of official duties, who is certified or eligible to apply for certification by the American Board of Psychiatry and Neurology, Inc. c. A psychologist with the health service provider designation, a psychological practitioner, a certified psychologist, or a psychological associate, licensed under the provisions of KRS Chapter 319. d. A licensed registered nurse with a master’s degree in psychiatric nursing from an accredited institution and two (2) years of clinical experience with mentally ill persons; or a licensed registered nurse, with a bachelor’s degree in nursing from an accredited institution, who is certified as a psychiatric and mental health nurse by the American Nurses Association and who has three (3) years of inpatient or outpatient clinical experience in psychiatric nursing and is currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general hospital or a private agency or company engaged in provision of mental health services or a regional community mental health and mental retardation program. e. A licensed clinical social worker licensed under provisions of KRS 335.100, or a certified social worker licensed under the provisions of KRS 335.080 with three (3) years of inpatient or outpatient clinical experience in psychiatric social work and currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general hospital or a private agency or company engaged in the provision of mental health services or a regional community mental health and mental retardation program. f. A marriage and family therapist licensed under the provisions of KRS 335.300 to 335.399 with three (3) years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency or company engaged in providing mental health services, or a regional community mental health and mental retardation program. g. A professional counselor credentialed under the provisions of KRS Chapter 335.500 to 335.599 with three (3) years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency or company engaged in providing mental health services, or a regional community mental health and mental retardation program. “Certified Alcohol and Drug Abuse Counselor” under KRS 309.080 means a person certified by the Kentucky Board of Certification of Alcohol and Drug Counselors pursuant to KRS 309.080 to 309.089. American LegalNet, Inc. www.USCourtForms.com