Notice Of Commitment Change Form. This is a North Carolina form and can be use in Special Proceedings Statewide.
Tags: Notice Of Commitment Change, DMH 5-79-01, North Carolina Statewide, Special Proceedings
STATE OF NORTH CAROLINA NOTICE OF COMMITMENT CHANGE Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services Facility Name: Facility Address: IN THE MATTER OF: File #:________________ Film #:________________ ___________ _______ (Physical location) Respondent’s Name:_______________________________________________________________ Client Record Number: _____________________ Unit/Building/Ward (When Applicable): Inpatient Outpatient Date of ___________________________ Substance Abuse Commitment___________ TO: Clerk of Superior Court, ______________________________ County This is to certify that the commitment status of the above-named respondent has changed due to the following: The respondent is no longer in need of inpatient hospitalization and is unconditionally discharged on _________(date). The respondent no longer meets the criteria for outpatient substance abuse commitment and is discharged on ______. (Date) The respondent is no longer in need of inpatient treatment and is conditionally released on ____________(date) to be followed by unconditional discharge on ______________(date). Conditions of release are: _________________________________________________________________________________ The respondent escaped breached conditions of release on ____________(date); and is discharged from unauthorized absence on _________________ (date). The respondent or legally responsible person signed a consent for voluntary treatment on ____________(date). The respondent was admitted as a voluntary minor and has turned 18 years of age. The respondent signed a consent for voluntary treatment on _______________ (date). The respondent was admitted to a 24-hour facility on an involuntary basis on _________________ (date). Therefore, outpatient commitment is terminated. The respondent has moved to another state or location of respondent is unknown so commitment is terminated on _________(date). The respondent is no longer in need of inpatient treatment. The respondent is released from inpatient commitment and is committed by the court to outpatient treatment for _______ days on _____________(date). The respondent was discharged from the 24-hour facility on _________________(date). The respondent is on a split commitment and is no longer in need of inpatient treatment. The respondent is released from inpatient hospitalization and is committed to outpatient treatment for __________ days on ___________ (date). The respondent was transferred to __________________________ in __________________ County on ____________(date). The respondent expired on _____________________ (date). Other (Specify):_____________________________________________________________________________________ _____________________________________________________________________ _________________________ Signature/Title Date NOTE: If current status is Inpatient Commitment, signature must be that of Attending Physician. If current status is Outpatient or Substance Abuse Commitment, signature must be that of Responsible Professional. Original: Clerk of Superior Court where petition initiated _________ (date). (Specify: _________________________________) Copy: Clerk of Superior Court where facility located __________(date). Clerk of Superior Court where outpatient or substance abuse commitment supervised _____________ (date). (Specify: _________________________________________________________________________). Medical Record Respondent and State’s Attorney __________ (date). Designated outpatient treatment center or physician _________ (Date).(Specify__________________________) Form No. DMH 5-79-01 Revised September 2001 NOTICE OF COMMITMENT CHANGE American LegalNet, Inc. www.USCourtForms.com