Certification By Peace Officer And Certifications By Other Qualified Person And Peace Officer
Download Free Print-Only PDF OR Purchase Interactive PDF Version of this Form
Certification By Peace Officer And Certifications By Other Qualified Person And Peace Officer Form. This is a Maryland form and can be use in Circuit-District Court Statewide.
Loading PDF...
Tags: Certification By Peace Officer And Certifications By Other Qualified Person And Peace Officer, CC-DC 14, Maryland Statewide, Circuit-District Court
CERTIFICATION BY PEACE OFFICER
I am a
sheriff,
police officer, or
deputy sheriff,
State police officer,
county police officer,
municipal or other local
Secret Service agent who is a sworn special agent of the United States Secret Service or
Treasury Department authorized to exercise powers delegated under 18 U.S.C. § 3056.
As to
(evaluee), I have personally
observed the
evaluee or
evaluee's behavior and, based on the
observation or
other information, have
reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or
others. Pursuant to Maryland Code, Health–General Article § 10-622, I have transported the evaluee to
(emergency facility) for evaluation.
Peace Officer
Date and Time
Department
I.D. No.
CERTIFICATIONS BY
OTHER PERSON QUALIFIED UNDER HG § 10-622 AND PEACE OFFICER
I am a
physician,
psychologist,
clinical social worker,
clinical nurse specialist in psychiatric and mental health nursing,
clinical marriage and family therapist,
health officer or
licensed clinical professional counselor,
psychiatric nurse practitioner,
a licensed
designee of a health officer. I have examined
(evaluee). Based on
the examination or
other information, I have reason to believe that the evaluee has a mental disorder and presents a danger to the life
or safety of the evaluee or others and, in accordance with Maryland Code, Health–General Article § 10-622, have
completed the attached Petition for Emergency Evaluation and have requested a peace officer to take into custody
and transport the evaluee to the nearest emergency facility for evaluation by a physician. The peace officer explained
to me the serious nature, meaning, and content of the petition and I asked the officer to proceed.
Date and Time
Physician or other Qualified Person under HG § 10-622
License No.
I have explained to the Petitioner the serious nature of the petition and the meaning and content of the petition.
Peace Officer
Date
Department
I.D. No.
CC-DC 14 (Rev. 10/2008)
American LegalNet, Inc.
www.FormsWorkflow.com
