STATE OF NORTH CAROLINA SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR Department of Health and Human Services INVOLUNTARY COMMITMENT Division of Mental Health, Developmental Disabilities, and Substance Abuse Services SUPPLEMENT TO SUPPORT IMMEDIATE HOSPITALIZATION (To be used in addition to “Examination and Recommendation for Involuntary Commitment, Form 572-01) CERTIFICATE The Respondent, _____________________________________________ requires immediate hospitalization to prevent harm to self or others because: I certify that based upon my examination of the Respondent, which is attached hereto, the Respondent is (check all that apply): Mentally ill and dangerous to self Mentally ill and dangerous to others In addition to being mentally ill, is also mentally retarded Signature of Physician or Eligible Psychologist Address: City State Zip: Telephone: Date/Time: Name of 24-hour facility: Address of 24-hour facility: CC: 24-hour facility Clerk of Court in county of 24-hour facility Note: If it cannot be reasonably anticipated that the clerk will receive the copy within 24 hours (excluding Saturday, Sunday and holidays) of the time that it was signed, the physician or eligible psychologist shall also communicate the findings to the clerk by telephone. NORTH CAROLINA _______________________ County Sworn to and subscribed before me this ________ day of ___________, 20__ (seal) ___________________________________ Notary Public My commission expires:________________ Pursuant to G.S. 122C-262 (d), this certificate shall serve as the Custody Order and the law enforcement officer or other person shall provide transportation to a 24-hr. facility in accordance with G.S. 122C-251. TO LAW ENFORCEMENT: See back side for Return of Service DMH 5-72-01-A COMMITMENT Revised September 2001 SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY CERTIFICATE TO SUPPORT IMMEDIATE HOSPITALIZATION American LegalNet, Inc. www.USCourtForms.com STATE OF NORTH CAROLINA SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR Department of Health and Human Services INVOLUNTARY COMMITMENT Division of Mental Health, Developmental Disabilities, and Substance Abuse Services RETURN OF SERVICE Respondent WAS NOT taken into custody for the following reason: I certify that this Order was received and served as follows: Date Respondent Taken into Custody Time AM PM Name of 24-Hour Facility Date Delivered Time Delivered AM Date of Return PM Name of Transporting Agency DMH 5-72-01-A COMMITMENT Revised September 2001 Signature of Law Enforcement Official SUPPLEMENT TO EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY CERTIFICATE TO SUPPORT IMMEDIATE HOSPITALIZATION American LegalNet, Inc. www.USCourtForms.com