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