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Request To Return Escapee Or Conditional Releasee Form. This is a North Carolina form and can be use in Special Proceedings Statewide.
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Tags: Request To Return Escapee Or Conditional Releasee, DMH 5-82-02, North Carolina Statewide, Special Proceedings
STATE OF NORTH CAROLINA
REQUEST TO RETURN ESCAPEE OR CONDITIONAL RELEASEE
Department of Health and Human Services
Division of Mental Health, Developmental Disabilities, and Substance Abuse Services
DATE: ______
TO: __________________________________ FROM: ________________________________
(Sheriff/Law Enforcement Officer)
(Facility)
(Where Facility is Located)
Patient’s name: ______________________________ Also known as______________________________
Hospital Number: ______________________________ SS#: ______________________________
Last known home address: _____________________________________________________ Admit date: _____________
Hospital Unit/Bldg/Ward______________________________
This is to notify you that the above named patient from ________________County
(home county)
The patient is:
ESCAPED on _________________
BREACHED THE CONDITION OF
HIS/HER RELEASE ON _________
Under involuntary commitment
following being charged with a violent crime and found not guilty by reason of insanity (NGRI) or
incapable of proceeding (HB 95)
A competent adult voluntarily admitted and in my opinion is reasonable foreseeable that:
1) he/she may cause physical harm to others or himself;
2) he/she may cause damage to property
3) he/she may commit a felony or a violent misdemeanor; or
4) the health or safety of the client may be endangered unless he/she is immediately returned to
the facility
A minor or incompetent adult voluntarily admitted
Admitted pending a judicial hearing
Under conditional release from the facility
Involuntarily committed or voluntarily admitted and under a DETAINER issued by
Patient was last seen:
Date:
Time:
Wearing:
Location:
Activity Area
Clinic
Dining room
Gym
Work Activity
Activity Trip
Courtroom
Elevator
Hallway
Unknown
Bathroom
Courtyard
Grill/Canteen
Medical Transport
Other ___________
Bedroom
Dayroom
Grounds
Stairway
The above named patient is to be taken into custody and returned to the above named facility pursuant to G.S. 122C205.
PATIENT IDENTIFYING INFORMATION
Race ______ Sex ___ Place of birth (state)_______ Date of birth ________ Age ____ Height ______ Weight ________
Eye color ____________ Hair color _____________ Hair style _____________________ Skin tone __________________
Scars/Marks/Tattoos ______________________________________________Facial features _________________________
Build ____________________ Gait ______________ Other distinguishing features __________________________________
Patient has vehicle at hospital
yes
no If yes, vehicle license number: ____________________ Vehicle lic state: ______
Type of vehicle: ________________________ Vehicle year: _________ Vehicle make: ________________
Vehicle style:______________ Vehicle color:______________
Dangerous to self
no
yes (specify) _________________________________________________________________
Dangerous to others: no
yes (specify)__________________________________________________________________
Avoids people
no
yes Medical Conditions/Impairments:___________________ Needs further treatment: yes
no
ADDITIONAL INFORMATION
Additional information that is reasonably necessary to assure the expeditious return of the client and protect the patient and/or
the general public (including possible locations and contacts): _________________________________________________
_____________________________________________________________________________________
Signature of Authorizing Physician
Printed name
Date
DISTRIBUTION WHEN REQUEST TO RETURN IS ISSUED:
Nursing Staff: HIM (original copy)
Official placing patient on detainer
Initial examiner if involuntarily committed
Area program (if appropriate)
Next of kin/legally responsible party
Any law enforcement office notified
Clerk of Superior Court in county of commitment
DMH 5-82-02
Revised September 2001
REQUEST TO RETURN ESCAPEE OR CONDITIONAL RELEASEE
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