STATE OF NORTH CAROLINA EVALUATION FOR ADMISSION / CONTINUED STAY Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services County Client Record # (Restrictive 24-hour Facilities) File # Voluntary Minors and Incompetent Adults File # NAME OF MINOR OR INCOMPETENT ADULT AGE BIRTHDATE SEX ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in facility) RACE M.S. County Phone LEGALLY RESPONSIBLE PERSON (Name and Address) Relationship Phone The above-named in follows: minor incompetent adult was examined on __, 20 __, at __ o’clock .m. . The results of the examination are as DESCRIPTION OF FINDINGS (Include indications for mental illness or substance abuse and need for further treatment or evaluation. Also include information provided by family members regarding the individual’s need for further treatment). (OVER) DESCRIPTION OF FINDINGS (continued): Form No. DMH 5-73-01 Revised September 2001 EVALUATION FOR ADMISSION / CONTINUED STAY (Restrictive 24-hour facilities) Voluntary Minors and Incompetent Adults American LegalNet, Inc. www.USCourtForms.com NOTABLE PHYSICAL CONDITIONS: CURRENT MEDICATIONS (Medical and Psychiatric): IMPRESSION / DIAGNOSIS: As a result of my examination, it is my opinion that the above-named individual: IS IS NOT mentally ill or a substance abuser IS IS NOT in need of further evaluation by the facility DOES NEED OR CAN BENEFIT DOES NOT NEED OR CANNOT BENEFIT from the care, treatment, habilitation or rehabilitation available at the facility RECOMMENDATION FOR DISPOSITION: Admit for treatment / rehabilitation (applies to initial hearings only) Admit for further diagnosis and evaluation not to exceed an additional 15 days following the initial hearing Continue treatment for days (applies to rehearings only) Other (Specify) This is to certify that this is a true and exact copy of the Evaluation For Admission / Continued Stay. Signature / Title - Responsible Professional Original Signature - Record Custodian Print Name of Responsible Professional Title Facility Name and Address Facility Name and Address City, State, Zip Date Telephone Number NOTE: Only copies to be introduced as evidence need to be certified. Original: Medical Record cc: Clerk of Superior Court Where facility is located Respondent’s Attorney State’s Attorney American LegalNet, Inc. www.USCourtForms.com