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 Page 1 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 2 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 3 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 4 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 5 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 6 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 7 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 8 of 9 American LegalNet, Inc. www.FormsWorkFlow.com 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 Page 9 of 9 American LegalNet, Inc. www.FormsWorkFlow.com