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 American LegalNet, Inc. www.USCourtForms.com