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Certificate Of Licensed Examiner Form. This is a West Virginia form and can be use in Circuit Court Statewide.
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Tags: Certificate Of Licensed Examiner, SCA-MH-904, West Virginia Statewide, Circuit Court
IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only
IN RE: INVOLUNTARY HOSPITALIZATION,
TREATMENT COMPLIANCE, OR TEMPORARY
PROBABLE CAUSE OF:
____________________________________________,
RESPONDENT
CASE NUMBER: ____________________________
(MH, TCO OR TPC #)
CERTIFICATE OF LICENSED EXAMINER
West Virginia Code: §§ 27-5-2, 3 & 4 AND §27-5-11
Instructions: All pages of this certificate must be fully completed.
I, ___________________________________________________ [Print Name of Licensed Physician, Licensed
Psychologist, Court authorized Licensed Independent Clinical Social Worker, or Court authorized Licensed
Advanced Nurse Practitioner with Psychiatric Certification or Physician Assistant], do hereby certify and state as
follows:
I have personally observed and examined __________________________________________________________
(full name of Respondent)
whose identifying information is believed to be,
DATE OF BIRTH ____/_____/________; WEIGHT __________;
HAIR COLOR ________________;
HAIR LENGTH ___________;
SEX ________; HEIGHT __________; EYE COLOR ______________; RACE ______________.
RESPONDENT'S LAST KNOWN ADDRESS: ________________________________________________
_______________________________________________________________________________________
PLACE OF BIRTH [state or country]_________________________________________________________
THE RESPONDENT IS:
A RESIDENT OF ___________________________________ COUNTY, ______________________ STATE.
on this date and my findings are as follows:
Date of Examination: ___________________________ Time:_______________
Place of the Examination: ______________________________________________________________
_______________________________, ________________________________________, West Virginia.
(City)
(County)
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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FINDINGS
1.
I find there is reason to believe the Respondent _______ IS _______ IS NOT
[ ] mentally ill
[
] addicted
[If the individual is being certified for addiction, initial the following if it is applicable]
__________[initials] I recommend that the individual be closely monitored because of the reasonable
likelihood that withdrawal or detoxification will cause significant medical complications.
2.
I further find that the Respondent ____ IS ____ IS NOT likely to cause harm to him/herself or others
DUE TO HIS/HER MENTAL ILLNESS OR ADDICTION.
3.
If the selection in question 2 above is “IS,” it is based on one or more of the following [check all
appropriate items from the list of five items below and detail the specific facts under each checked
item]:
The individual has inflicted or attempted to inflict bodily harm on another: [describe]
______________________________________________________________________________
______________________________________________________________________________
The individual, by threat or action, has placed others in reasonable fear of physical harm to
themselves [describe]
______________________________________________________________________________
______________________________________________________________________________
The individual, by action or inaction, has presented a danger to others in his or her care:
[describe]
______________________________________________________________________________
______________________________________________________________________________
The individual has threatened or attempted suicide or serious bodily harm to himself or herself:
[describe]
______________________________________________________________________________
______________________________________________________________________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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The individual is behaving in such a manner as to indicate that he or she is unable, without
supervision and the assistance of others, to satisfy his or her need for nourishment, medical care,
shelter or self-protection and safety so that there is a substantial likelihood that death, serious
bodily injury, serious physical debilitation, serious mental debilitation or life-threatening disease
will ensue unless adequate treatment is afforded: [describe]
______________________________________________________________________________
______________________________________________________________________________
4.
[You must complete this question if you have indicated “mental illness” in question 1.]
The specific, CURRENT, symptoms and behavior I HAVE OBSERVED on which my finding of mental illness is
based are:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
___________________________________________________________________________________________________
Any other specific symptoms and behavior on which my finding of mental illness is based are:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
5.
[You must complete this question if you have indicated “addiction” in question 1.]
The specific manifestations which have occurred WITHIN 30 DAYS prior to the filing of the
petition/application in this action upon which my finding of addiction is based are: [Check all that
apply; you MUST check at least one.]
Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or
home
Specify: ______________________________________________________________________
_____________________________________________________________________________
Recurrent substance use in situations in which it is physically hazardous
Specify: ______________________________________________________________________
_____________________________________________________________________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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Recurrent substance-related legal problems
Specify: ______________________________________________________________________
_____________________________________________________________________________
Continued substance use despite knowledge of having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance
Specify: _____________________________________________________________________
____________________________________________________________________________
Other specific symptoms and behavior on which my finding of “addiction” is based are:
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
6.
I received information relevant to this evaluation from the following sources [Consult as many sources as
possible; check all that apply]:
______ Respondent
______ Family Members
7.
_______ Petitioner
_______Medical Record
______Physician
_______ Other [list]: ____________________________________________
Prior history of behavioral health services in the following settings: (add # for clarity)
Type of Treatment
Yes
No
Unknown
Compliant
NonCompliant
Date(s)
Outpatient
Voluntary Inpatient or
Residential Treatment
Previous Commitment(s)
If “no” marked in outpatient, or voluntary inpatient or residential treatment columns above, why are these less
restrictive alternatives not being attempted at this time?
Explain: ___________________________________________________________________________________
__________________________________________________________________________________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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8.
List all medications currently taking, or prescribed and should be taking:
Name of Medication:
Dosage:
Duration:
1.
2.
3.
4.
5.
9.
Are there any acute medical conditions that require immediate attention? (Circle One)
Yes
No
If “Yes”, list the condition(s): ___________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
10.
Is Medical Clearance Examination NECESSARY? (Circle One) Yes No Unknown
If yes, has it been completed or arranged to be completed, prior to involuntary admission to a mental health
facility. (Circle One) Yes
No
Unknown
Medical Screening was completed at: ______________________________________________________
Medical Screening arranged to be completed at: ______________________________________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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11.
The results of my evaluation suggest the following factor(s) are present, or have been present in the past:
[check all that apply]
Factors
General Information [check (Τ) if yes, list date(s) when present]
Thoughts of
Suicide
Ideation_______________
Plan________________ Intent_________________
Other Prior History Yes
No Explain/give examples: ________________________
_________________________________________________________________________
Thoughts of
Homicide
Ideation_______________
Plan________________ Intent_________________
Other Prior History Yes
No Explain/give examples: ________________________
_________________________________________________________________________
Head Injury/
Type(s): _______________________________________________________________
Neurological
_________________________________________________________________________
D
Chronic Medical
Type(s): _______________________________________________________________
Problems
_________________________________________________________________________
Limitations to
Explain: ________________________________________________________________
Support System _________________________________________________________________________
History of Legal
Type(s); Explain: _________________________________________________________
Infractions
_________________________________________________________________________
Past History of
Harmful Behavior
12.
Explain: ________________________________________________________________
_________________________________________________________________________
The results of my evaluation suggest the following factors related to addiction are present [check all that
apply]:
Factor(s)
Yes
No
General Information
Substance Use:
Used Periodically?:
Used Frequently?:
Used Constantly?:
Type(s)/Amount: _________________________________________
Type(s)/Amount: _________________________________________
Type(s)/Amount __________________________________________
Public Intoxication
Charges
Frequency in Past 90 Days / Dates: ____________________________
________________________________________________________
Substance Abuse to the
Point of Incapacitation
Explain: _________________________________________________
________________________________________________________
Employment Instability
Explain: _________________________________________________
________________________________________________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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13.
DSM - Diagnostic Impression (include all five axes): ___________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
14.
Clinician Rating of Treatment Needs [circle your impression]:
No observable seriously
harmful behavior (SHB).
2
3
Slight probability of
SHB.
Mild probability of SHB.
Moderate probability of
SHB.
High probability SHB.
Outpatient therapies
needed.
0
Crisis residential unit
(CRU) appropriate. 24hour supervision needed.
Immediate
hospitalization in a 24hour locked facility
needed.
Should be monitored
closely until hospitalized.
Immediate
hospitalization in a 24hour locked facility
needed.
1
No treatment needed.
15.
4
Based upon such examination and the information contained in this certificate, I therefore certify as follows:
[Initial only ONE of the following recommendations]:
__________
__________
__________
__________
The Respondent should be committed for further evaluation pursuant to § 27-5-3 [probable cause
hearing only]
The Respondent should be finally committed pursuant to § 27-5-4 (k) for a temporary observation
period (TOP) not to exceed six (6) months [final commitment hearing only]
The Respondent should be finally committed for an indeterminate period not to exceed two (2)
years, unless, previous to the expiration of this period, this order is modified or extended by
further order of this Court pursuant to the provisions of § 27-5-4 (k) and [final commitment hearing
only]
The Respondent does not require hospitalization [probable cause or final commitment hearing]
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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16.
[Initial the following if ALL the matters contained in the statement are applicable]
_________
Notwithstanding the foregoing, I further believe that the respondent's circumstances make
him/her amenable to treatment upon an outpatient basis in a nonhospital or nonresidential
setting pursuant to a voluntary treatment agreement and that appropriate outpatient services
are available and recommend that the court hear evidence on this issue.
Paragraphs 17 and 18 are to be completed in addition to the forgoing only by examining psychiatrists or
licensed psychologists:
17.
[Complete this paragraph only for potential Temporary Probable Cause cases under W.Va. Code §
27-5-11(c): Kanawha and Raleigh Counties only. Initial if applicable]
_________
Based upon my examination and observation of the Respondent and the information contained in
this certificate, I certify that the Respondent is more likely than not to cause serious harm to
self or to others as a result of mental illness if not immediately restrained and that the best
interests of the Respondent would be served by Respondent’s immediate hospitalization.
18.
[Complete this paragraph only for Treatment Compliance cases filed under W.Va. Code § 27-511(b): Brooke, Cabell, Hancock, Kanawha, Marion, Ohio, Raleigh, Wirt, & Wood Counties only.
Initial all that apply]
Based upon personal examination of the Respondent and the information contained in this certificate, it is
my opinion that:
_________
_________
19.
The Respondent, without the aid of medication is likely to cause serious harm to himself or
herself or to others.
The Respondent, without the aid of prescribed treatment is likely to cause serious harm to
himself or herself or to others.
Information regarding examiner completing this certificate: [please print or type information]
Name:____________________________________________________________________________________
Address: ______________________________________________ Telephone Number: (
(city)
(state)
(zip)
License to Practice
[
[
[
[
]
]
]
]
Medicine
[ ] Social Work
Osteopathy
[ ] Nursing
Psychology
[ ] Psychiatry
Physician Assistant
) _______________
Registration/License Number:
_________________________
Signature of Examiner:
_______________________________________________Date: _______________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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Licensed Independent Social Workers, Advanced Nurse Practitioners with Psychiatric Certification, and Physician Assistants
are limited by law to completion of Probable Cause examinations, and cannot examine Respondents for Final Commitment
proceedings.
21.
The person completing this certificate [check only one]:
Is employed by a the local Community Mental Health Center [insert name of Center]:
______________________________________________________________________________
Has contracted to provide examinations for involuntary commitment proceeding with the local Community
Mental Health Center [insert name of Center]:
______________________________________________________________________________
Is neither employed by nor contracts for services with the local Community Mental Health Center.
If this item is checked, you MUST have the Community Mental Health Center complete the following:
The examination reflected by this certificate was as required by law provided or arranged by the Community
Mental Health Center or, if the examiner is neither employed or contracted by the Community Mental Health
Center, the examination is APPROVED and the Community Behavioral Health Center hereby waives its
duty to provide or arrange for this examination.
Signature of Center Representative: ________________________________________________
Title: _______________________________________________ Date: ___________________
C CL MH07 INV 10; SCA-MH 904 / 11-09
CERTIFICATE OF EXAMINER
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