STATE OF NORTH CAROLINA Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services County ___________________ File # ____________ EXAMINATION AND RECOMMENDATION TO DETERMINE NECESSITY FOR INVOLUNTARY COMMITMENT Client Record # ____________ NAME OF RESPONDENT: AGE BIRTHDATE ADDRESS (Street, Apt., Route, Box Number, City, State, Zip - Use facility address after 1 year in facility) Film # ____________ SEX RACE M.S. County Phone LEGALLY RESPONSIBLE PERSON NEXT OF KIN (Name and address) Relationship Phone PETITIONER (Name and address) Relationship Phone The above-named respondent was examined on ____________, 20___ at ____________ o’clock ____.M. at ______________ __________________________________________________. Included in the examination was an assessment of the respondent’s: (1) current and previous mental illness or mental retardation including, if available, previous treatment history; (2) dangerousness to self or others as defined in G.S. 122C-3 (11*); (3) ability to survive safely without inpatient commitment, including the availability of supervision from (1) current and previous substance abuse family, friends, or others; and (4) capacity to make an informed decision concerning treatment. including, if available, previous treatment history; and (2) dangerousness to himself or others as defined in G.S. 122C-3 (11*). The following findings and recommendations are made based on this examination. *See Statutory Definitions on Reverse Side. SECTION I - CRITERIA FOR COMMITMENT Inpatient. It is my opinion that the respondent is: mentally ill; dangerous to self; (1st Exam - Physician or Psychologist) (2nd Exam - Physician only) Outpatient. It is my opinion that: (Physician or Psychologist) dangerous to others In addition to being mentally ill is also mentally retarded the respondent is mentally ill the respondent is capable of surviving safely in the community with available supervision based upon the respondent’s treatment history, the respondent is in need of treatment in order to prevent further disability or deterioration which would predictably result in dangerousness as defined by G.S. 122C-3 (11*) the respondent’s current mental status or the nature of his illness limits or negates his/her ability to make an informed decision to seek treatment voluntarily or comply with recommended treatment Substance Abuse. It is my opinion that the respondent is: a substance abuser (1st Exam -Physician or Psychologist; 2nd Exam - If 1st dangerous to himself or others exam done by Physician, 2nd exam may be done by Qual. Prof.) SECTION II - DESCRIPTION OF FINDINGS Clear description of findings (findings for each criterion checked above in Section I must be described): (over) Form No. DMH 5-72-01 Revised September 2001 EXAMINATION AND RECOMMENDATION FOR INVOLUNTARY COMMITMENT American LegalNet, Inc. www.FormsWorkflow.com Current Medications (medical and psychiatric) Notable Physical Conditions: Impression/Diagnosis: SECTION III - RECOMMENDATION FOR DISPOSITION Inpatient Commitment for _________ days (respondent must be mentally ill and dangerous to self or others) Outpatient Commitment (respondent must meet ALL of the first four criteria outlined in Section I, Outpatient) Proposed Outpatient Treatment Center or Physician: (Name)___________________________________________________ (Address and Phone Number)____________________________________________________________________ ______________________________________________________________________ Substance Abuse Commitment (respondent must meet both criteria outlined in Section I, Substance Abuse) Release respondent pending hearing - Referred to:__________________________________________________ Hold respondent at 24-hour facility pending hearing - Facility __________________________________________ Respondent does not meet the criteria for commitment but custody order states that the respondent was charged with a violent crime, including a crime involving assault with a deadly weapon, and that he was found not guilty by reason of insanity or incapable of proceeding: therefore, the respondent will not be released until so ordered following the court hearing. Respondent or Legally Responsible Person Consented to Voluntary Treatment Release Respondent and Terminate Proceedings (insufficient findings to indicate that respondent meets commitment criteria) Other (Specify) ______________________________________________________________________________________ ________________________________________________ M.D. Physician Signature This is to certify that this is a true and exact copy of the Examination and Recommendation for Involuntary Commitment ____________________________________________________ Signature/Title - Eligible Psychologist/Qualified Professional ____________________________________________________ Original Signature - Record Custodian ____________________________________________________ Print Name of Examiner ____________________________________________________ Title Address or Facility City and State ____________________________________________________ Address or Facility ____________________________________________________ Date NOTE: Only copies to be introduced as evidence need to be certified. Telephone Number Original: Medical Record CC: Clerk of Superior Court where petition was initiated (initial hearing only) Clerk of Superior Court where 24-hour facility is located or where outpatient treatment is supervised Respondent and State’s Attorneys, when applicable Proposed Outpatient Treatment Center or Physician (Outpatient Commitment); Area Program / Physician (Substance abuse Commitment) NOTE: If it cannot be reasonably anticipated that the clerk will receive the copies within 48 hours of the time that it was signed, the physician or eligible psychologist/qualified professional shall communicate his findings to the clerk by telephone. *STATUTORY DEFINITIONS “Dangerous to self”. Within the recent past: (a) the individual has acted in such a way as to show: (1) that he would be unable without care, supervision, and the continued assistance of others not otherwise available, to exercise self-control, judgment, and discretion in the conduct of his daily responsibilities and social relations or to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety; and (2) that there is a reasonable probability of his suffering serious physical debilitation within the near future unless adequate treatment is given. A showing of behavior that is grossly irrational, of actions that the individual is unable to control, of behavior that is grossly inappropriate to the situation, or of other evidence of severely impaired insight and judgment shall create a prima facie inference that the individual is unable to care for himself; or (b) the individual has attempted suicide or threatened suicide and that there is a reasonable probability of suicide unless adequate treatment is given; or (c) the individual has mutilated himself or attempted to mutilate himself and that there is a reasonable probability of serious self-mutilation unless adequate treatment is given. NOTE: Previous episodes of dangerousness to self, when applicable, may be considered when determining reasonable probability of physical debilitation, suicide, or self-mutilation. “Dangerous to others”. Within the recent past, the individual has inflicted or attempted to inflict or threatened to inflict serious bodily harm on another, or has acted in such a way as to create a substantial risk of serious bodily harm to another, or has engaged in extreme destruction of property; and that there is a reasonable probability that this conduct will be repeated. Previous episodes of dangerousness to others, when applicable, may be considered when determining reasonable probability of future dangerous conduct. “Mental illness:. (a) when applied to an adult, an illness which so lessens the capacity of the individual to use self-control, judgment, and discretion in the conduct of his affairs and social relations as to make it necessary or advisable for him to be under treatment, care, supervision, guidance or control; and (b) when applied to a minor, a mental condition, other than mental retardation alone, that so lessens or impairs the youth’s capacity to exercise age adequate self-control and judgment in the conduct of his activities and social relationships so that he is in need of treatment. “Substance abuser”. An individual who engages in the pathological use or abuse of alcohol or other drugs in a way or to a degree that produces an impairment in personal, social, or occupational functioning. Substance abuse may include a pattern of tolerance and withdrawal. American LegalNet, Inc. www.FormsWorkflow.com