Request To Return Escapee Or Conditional Releasee Form. This is a North Carolina form and can be use in Special Proceedings Statewide.
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 American LegalNet, Inc. www.USCourtForms.com