HomeMy WebLinkAboutMINUTES - 11042008 - C.39 TO: BOARD OF SUPERVISORS Contra
FROM: David Twa _
County Administrator ;
" s Costa
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DATE: November 4, 2008 °SrA�oUza� County
SUBJECT: Adopt Designations and Authorizations under Welfare & Institutions Code
SPECIFIC REQUEST(S)OR RECOMMENDATION(S)&BACKGROUND AND JUSTIFICATION
RECOMMENDATION: ADOPT Resolution No. 2008/700 designating facilities and persons
authorized to involuntarily detain person, adopting policies and procedures, and making
appointments under the Welfare and Institutions Code and the Lanterman-Petris-Short Act, as
recommended by the County Administrator.
FISCAL IMPACT: None.
BACKGROUND: Under the Welfare and Institutions Code and the Lanterman-Petris-Short
(LPS) certain authorizations, delegations, policies and procedures must be approved. Over the
years the Board of Supervisors has passed a series of resolutions making the required
designations and authorizations. Due to the number of years and the series of changes, it is
difficult to determine which parts of each resolution are still in effect.
In addition, on July 1, 2008, the LPS Intake function and. duties were transferred from the
Employment and Human Services Department to the Health Services Department. This
resolution appoints the Health Services Director as the Public Conservator and makes other
appointments necessary due to the transfer of duties
The attached resolution is intended to clean up the confusion caused by the prior resolutions
and obtain new Board of Supervisors approval for authorizations and designations. This
resolution rescinds all prior resolutions.
CONTINUED ON ATTACHMENT: _YES SIG URE:
RECOMMENDATION OF COUNTY ADMINISTRATOR [i' RECOMMENDATION OF BCTARD COMMITTEE
-4-,APPROVE _OTHER
SIGNAT
ACTION OF BOARD ON APPROVE AS RECOMMENDED OT ER
VOTE OF SUPERVISORS I HEREBY CERTIFY THAT THIS IS A TRUE
AND CORRECT COPY OF AN ACTION TAKEN
V` UNANIMOUS (ABSENT ) AND ENTERED ON THE MINUTES OF THE
BOARD OF SUPERVISORS ON THE DATE SHOWN.
AYES: NOES:
ABSENT: ABSTAIN:
ATTESTED
CONTACT: DAVID TWA,CLERK O THE BOARD
OF SUPERVISORS AND COUNTY
ADMINISTRATOR
CC: Health Services Director
HSD Mental Health Division Director
County Administrator
County Counsel BY DEPUTY
THE BOARD OF SUPERVISORS OF CONTRA COSTA COUNTY, CALIFORNIA
Adopted this Resolution on November 4, 2008 by the following vote: sE L
AYES: GLCia, tWdriz, piepho, gon, (& e aov
7 ✓
NOES: ox a0+aumrt
ABSENT: Nolle
�'osT• __ •c3`
`4 COUtI't�
ABSTAIN:
SUBJECT: In the matter of Designations ) Resolution No. 2008/700
and Authorizations under Welfare and )
Institutions Code and the Lanterman-Petris- )
Short Act )
The Contra Costa County Board of Supervisors hereby RESOLVES that:
I. RECISSION OF PRIOR RESOLUTIONS PERTAINING TO THE LANTERMAN-PETRIS-
SHORT ACT. The Board of Supervisors hereby rescinds all prior resolutions pertaining to
the Welfare and Institutions Code Section 5000 et seq., and the Lanterman-Petris-Short
Act in their entirety.
II. FACILITY DESIGNATIONS.
1. Under California Law, Welfare and Institutions Code Section 5000 et seq., provision is
made that the Board of Supervisors designate facilities that are authorized to
involuntarily detain persons in order to provide evaluation and treatment services, and
intensive treatment, and that such facilities be approved by the State Department of
Mental Health. The Board of Supervisors designates the following hospitals as
facilities for involuntary psychiatric determination:
I hereby certify that this is a true and correct copy of an
action taken and entered on the minutes of the Board of
Supervisors on the date shown
ATTESTED: November 4,2008
DAVID TWA, Clerk of the Board of Supervisors
And County Administrator
Byj�� Deputy
cc: Health Services—Mental Health r
County Administrator's Office (Sansoe)
County Counsel (Ranch)
RESOLUTION NO. 2008/700
Page 2
A. Contra Costa Regional Medical Center
2500 Alhambra Avenue, Martinez, California 94553
B. John,Muir Behavioral Health Center
2740 Grant Street, Concord, California 94520
C. Napa State Hospital
2100 Napa-Vallejo Highway, Napa California 94558
2. Under California Law, Welfare and Institutions Code Section 5150, provision is made
that the following person(s) may, upon probable cause, take a person into custody, or
cause the person to be taken into custody, and place the person in a facility
designated by the County and approved by the State Department of Mental Health as
a facility for 72-hour evaluation and treatment. The persons who may take such
actions include:
A. Peace officers, including park peace officers and regional park peace officers;
B. A member of the attending staff of the evaluation facility (so designated by the
County) who is authorized to admit a person involuntarily. [California Code of
Regulations, Title 9, Section 823 et seq.]
C. As designated by the Local Mental Health Director, qualified licensed mental
health professionals of Contra Costa Health Services, including psychiatrists,
psychologists, clinical social workers, marriage and family therapists, registered
nurses, licensed vocational nurses, and licensed psychiatric technicians
[California Code of Regulations, Title 9, Section 622 et seq].
D. As designated by the Local Mental Health Director, qualified licensed health
professionals of specified local hospitals located within Contra Costa County
(Kaiser Permanente Medical Centers, John Muir Medical Centers, Sutter Delta
Medical Center, Doctors Medical Center) inclusive of emergency department
physicians, psychiatrists, psychologists and social workers.
3. For Designees herein, all rights and procedural protection of clients are to be strictly
adhered to as outlined in the Welfare and Institutions Code, in state and federal
judicial decisions interpreting these statutes, and all other federal and state statutes
and regulations, including reporting obligations.
III. ADOPTION OF POLICIES AND PROCEDURES FOR AUTHORIZING INVOLUNTARY
PSYCHIATRIC DETERMINATIONS. Pursuant to the Lanterman-Petris-Short Act
(Division 5, Section 5000 of the Welfare and Institutions Code), the Board of Supervisors
hereby adopts the attached "Policy No. 714, Implementation of Welfare and Institutions
Code Section 5150" (Attachment A), which is incorporated herein by reference.
RESOLUTION NO. 2008/700
Page 3
IV. CONSERVATORSHIP AGENCIES, PERSONS AND INVESTIGATORS. Pursuant to
Section 5008 (g), 5201, 5202, and 5351 of the Welfare and Institutions Code, the
following are designated as agencies for the following functions:
1. The County Health Services Department is the designated agency, and its employees
are the persons, to provide conservatorship investigation services (Sections 5008 (g)
and 5352.) In connection therewith,the Health Services Department may contract with
other public agencies in order to carry out its responsibilities hereunder.
2. The County Health Services Department is the designated agency, and its employees
are the persons, to provide pre-petition screening and to prepare and file petitions for
evaluation (sections 5201 and 5202). The Health Services Director is responsible for
administering these functions, and he shall make the designations referred to in
Sections 5151, 5208, 5228, and 5251.
3. The County's Health Services Director and the County Health Services Department
are the agencies, officers, and/or employees which may be appointed conservator
pursuant to Section 5355; and
4. The County's Health Services Director may be appointed Temporary Conservator
pursuant to Section 5352.
V. CONSERVATORS. Pursuant to Section 5355, the Director of the County Health Services
Department is the County Public Conservator and the County's Health Services
Department may designate officers and employees to serve as Deputy Conservators.
VI. PROPERTY TRUST OFFICER. The Director of the County Health Services Department
is authorized to appoint a Property Trust Officer and Deputy Conservator. The designated
Trust Officer is authorized to take all necessary actions to manage and conserve the
income and assets of persons for whom the Court has designated the Director of the
County Health Services Department to act as Temporary LPS Conservator of the Estate
or LIPS Conservator of the Estate.
VII. EFFECTIVE DATE. This resolution is effective on the day following the date of action by
the Contra Costa County Board of Supervisors.
RESOLUTION NO. 2008/700
ATTACHMENT A
Contra Costa County POLICY NO. 714
Health Services Department
Review Date: December 2010
Mental Health Division
POLICY: Date APov D
ecember 3. 2007
IMPLEMENTATION OF WELFARE AND y:Xy. 111ed1:1i?
INSTITUTIONS CODE SECTION 5150 bo-nna M.Wiganif. LC
W F/
Mental Health Directolv
POLICY: IMPLEMENTATION OF WELFARE AND INSTITUTIONS CODE
SECTION 5150
I. PURPOSE
To provide guidelines to Contra Costa Health Department staff and Community Hospital
Emergency Department staff who are designated by the Local Mental Health Director to
initiate Section 5150 of the Welfare & Institutions Code Chapter 5000, known as the
Lanterman-Petri s-Short Act.
Section 5150 of the Welfare and Institutions Code states: "When any person, as a result
of mental disorder, is a danger to others, or to himself or herself, or gravely
disabled, a peace officer, member of the attending staff, as defined by regulation, of
an evaluation facility designated by the county, designated members of a mobile
crisis team provided by Section 5651.7 (section deleted),or other professional person
designated by the county may, upon probable cause, take, or cause to be taken, the
person into custody and place him or her in a facility designated by the county and
approved by the State Department of Mental Health as a facility for 72 hour
treatment and evaluation."
IL REFERENCES
Welfare and Institution Code Section 50001ff.
Board of Supervisors Board Resolution 2007/457
California Code of Regulations, Title 9
111. POLICY
A. Under Welfare and Institutions Code Section 5150, provision is made that certain
professionals may, upon probable cause, take a person into custody, or cause the
person to be taken into custody, and place the person in a facility designated by the
The legislative intent of the LPS Act enacted in 1967 was to end the inappropriate,indefinite and involuntary
commitment of mentally disordered person,developmentally disabled persons and persons impaired by chronic
alcoholism, The Act created time-specific legal holds,usually with some measure of due process attached to each
hold. Section 5150 of the W&I Code for evaluation and treatment is the first of these legal holds.
Implementation of Welfare and Institutions Code Section 5 150 Page I of—2
Contra Costa County POLICY NO. 714
Health Services Department Review Date:December 2010
Mental Health Division
POLICY: Date Approved: December 3,2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
county and approved by the State Department of Mental Health as a facility for 72-
hour evaluation and treatment. The professionals who may take such actions include:
1. Peace officers, including park peace officers and regional park peace officers. This
includes the law enforcement agencies of Antioch, Brentwood, Clayton, Concord,
Danville, El Cetrite, Hercules, Kensington, Lafayette, Martinez, Moraga, Oakley,
Orinda, Pinole, Pittsburg, Pleasant Hill, Richmond, San Pablo, San Ramon, Walnut
Creek, Contra Costa Sheriff's Dept, Bay Area Rapid Transit, and East Bay Regional
Park District.
2. A member of the attending staff, as designated by the Local Mental Health
Director, who has responsibility for the care and treatment of the client on the staff
of Contra Costa County's 5150 Designated Evaluation Facilities. This includes
Contra Costa Regional Medical Center and John Muir Behavioral Health Center.
[California Code of Regulations,Title 9, Section 823 et seq.]
3. Professional staff of Contra Costa Health Department as designated by the
Local Mental Health Director. In the Mental Health Division, this includes
Licensed Psychiatrists, Licensed Psychologists, Licensed Clinical Social Workers,
Licensed Marriage and Family 'Therapists, Registered Nurses, Licensed Vocational
Nurses, and Licensed Psychiatric Technicians [California Code of Regulations,
Title 9, Section 622 et seq.]; and Ambulatory Care Psychiatrists. The authority to
detain under W&I 5150 is limited to the role and responsibility as a Contra Costa
County employee under the auspices of the specific service site with which the
employee is associated.
4. Professional staff at the Medical Facilities and Kaiser Medical Centers located
in Contra Costa County who are designated by the Local Mental Health
Director. For those Medical Facilities(Hospital) with a Memorandum of
Understanding on file between the Mental Health Director and Hospital,
designated professional staff including Emergency Department Physicians,
Licensed Psychiatrists, Licensed Psychologists and Licensed Social Workers who
are authorized by the Hospital, approved by the Mental Health Director and
receive 5150 training.
B. There are two (2) Designated Facilities under Welfare and Institutions Code Section
5000 authorized by Contra Costa County and approved by the State Department of
Mental Health to involuntarily detain persons in order to provide psychiatric
evaluation and treatment services, and intensive treatment:
1. Contra Costa Regional Medical Center
2500 Alhambra Avenue,Martinez, California 94553
Implementation of Welfare and Institutions Code Section 5150 Page 2 of 8
i
i
Contra Costa County POLICY NO. 714
Health Services Department
Mental Health Division Review Date: December 2010
POLICY: Date Approved: December 3, 2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
2. John Muir Behavioral Health
2740 Grant St., Concord, California 94520
C. All designated staff authorized under Welfare and Institutions Code to initiate an
application for 72-hour Detention for Evaluation and Treatment or to detain a person
pursuant to Section 5150 of the Welfare and Institution Code must adhere to all laws
and regulations enacted to protect the rights of a person.
1. These undeniable rights include:
a) The right to treatment services which promote the potential of the person to
function independently;
b) The right to dignity, privacy, and humane care; the right to be free from
harm, including unnecessary or excessive physical restraint, isolation,
medication, abuse, or neglect;
c) A right to prompt medical care and treatment.
2. As required by California Welfare and Institutions Code §5520, Patients' Right
Advocates may carry out periodic reviews of facilities for compliance with
patients' rights laws and regulations. A Patients' Rights Handbook prepared by
the State Department of Mental Health must be available to anyone detained.'
3. Except in cases of emergency (defined in W&I Code §5008), psychotropic
medications shall not be given without consent until after a finding of "lack of
capacity" at an administrative Riese hearing. "Emergency" means a situation in
which action to impose treatment over the person's objection is immediately
necessary for the preservation of life or the prevention of serious bodily harm to
the patient or others, and it is impracticable to first gain consent.
D. Every effort must be made to address the language, ethnic or cultural needs of the
person for whom a 5150 is being considered. Absent language capacity, arrangements
should be made for interpretation/translation assistance.
III. PROCEDURE
A. Under W&I Code 5150, authorized staff must fill out the "Application for 72-Hour
Detention for Evaluation and Treatment." stating the circumstances under which the
'Patients Rights Handbooks can'be obtained by contacting the Contra Costa County's Patient Rights Office.
Implementation of Welfare and Institutions Code Section 5150 Page 3 of 8
Contra Costa County POLICY NO, 714
Health Services Department Review Date: December 2010
Mental Health Division
POLICY: Date Approved: December 3,2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
person's condition was called to their attention, and has probable cause to believe that
the person is, as a result of a mental disorder, a danger to himself or herself,or others
or gravely disabled.
1. When determining if probable cause exists to detain a person, all available
relevant information about the historical course of the person's mental disorder
shall be considered if it has a reasonable bearing on the determination as to
whether the person is a danger to self and/or others, or is gravely disabled as a
result of the mental disorder". This includes evidence presented by the person
who has provided or is providing mental health or related support services and
evidence presented by family members. (If the probable cause is based on the
statement of a person other than the officer, member of the attending staff or
professional person, such person shall be liable in a civil action for intentionally
giving a statement, which he or she knows to be false. (§5150.05)
2. In determining if someone is a danger to self,this criteria may be either a
deliberate intention to injure oneself(i.e. overdose)or a disregard of personal
safety to the point where injury is imminent(i.e. wandering about in heavy
traffic). The danger must be present, immediate, substantial,physical, and
demonstrable.
Documentation could include some or all of the following:
• Words or actions intent to commit suicide or bodily harm.
• Words or actions indicating gross disregard for personal safety.
• Words or actions indicating a specific plan for suicide.
• Means available to carry out suicide plan (i.e. pills, firearms present or
available).
3. In determining if someone if a danger to self or others, the legal criterion of danger
to self or others has been narrowly defined by the courts to mean "a demonstrated
danger of substantial harm" (People v. Superior Court 1.48 Cal. App. 3d 990, 196
Cal. Rptr. 431 (1983)).
The danger must be physical, not psychological or social harm. An adolescent is
not a danger to self merely because he associates with the wrong friends in places
where drugs are present. A person is not a danger to self because he engages in
behavior that a provider thinks is not beneficial for him or that may eventually do
him harm.
4. In determining if someone is a danger to others, it should be based on words or
actions that indicate the person in question either intends to cause hann to a
Im lementation of Welfare and Institutions Code Section 5150 1 Page 4 of 8
Contra Costa County POLICY NO. 714
Health Services Department
Mental Health Division Review Date: December 2010
POLICY: Date Approved: December 3, 2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
particular individual or intends to engage in dangerous acts with gross disregard
for the safety of others.
Documentation could include some or all of the following:
• Threats against particular individuals.
• Attempts to harm certain individuals.
• Means available to carry out threats or to repeat attempts (i.e. firearms, or
other weapons).
• Expressed intention or attempts to engage in dangerous activity.
• Actual threats of intent to harm in which there is a reasonable suspicion on the
part of the evaluator that the person will carry out their plan.
It is important to note on the 5150 application, the person's actual plan and any
past history of carrying out dangerous behaviors. Civil commitment for danger to
others is intended to apply to persons who have committed, or are believed about
to commit, a violent behavior.
5. In determining if someone is gravely disabled,the decision must be based on the
individual's current condition, although past events may be considered. The
standard of the condition must be judged by the client's current situation
(Conservatorship of Neal 190 Cal. App. 3d 685, 689, 235 Cal. Rptr. 577, (1987)).
The person must be unable to provide for basic personal needs as a result of a
mental disorder. Mere inability to provide for needs is not sufficient. Nor is a
refusal of treatment evidence of grave disability. Note also that,regardless of the
person's past, the question is whether they are presently gravely disabled.
Furthermore, a person is not"gravely disabled"if that person can survive safely
without involuntary detention with the help of responsible family, friends, or others
who are both willing and able to help provide for the person's basic personal needs
for food, clothing, or shelter. However, unless they specifically indicate in writing
their willingness and ability to help, family friends or others shall not be considered
willing or able to provide this help (W&I Section 5250.[d][1][2]).
Documentation could include some or all of the following:
• Signs of malnourishment or dehydration.
• Inability to articulate a plan for obtaining food.
• No food available in the house or at hand if not in a house.
• Irrational beliefs about food that is available(i.e. it's poisoned, inedible,etc.).
• Destruction or giving away of clothing to the point where the person cannot
clothe themselves.
Inn lementation of Welfare and Institutions Code Section 5150 Pae 5 of 8
Contra Costa County POLICY NO. 714
Health Services Department Review Date: December 2010
Mental Health Division
POLICY: Date Approved: December 3,2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
Definitions (Gravely Disabled)
i. "Gravely Disabled Minor"means a minor who, as a result of a mental disorder,
is unable to use the elements of life which are essential to health, safety, mid
development, including food, clothing and shelter, even though provided to the
minor by others."SECTION 5585.25 W&I CODE
ii. "Gravely disabled"ineans a condition in which a person, as a result of a mental
disorder, is unable to provide for his or her basic personal needs.for food,
clothing and shelter. SECTION 5008(h) W&I CODE.
B. When a person is taken into custody for evaluation, or within a reasonable time
thereafter, unless a responsible relative, guardian or conservator of the person in
possession of the person's personal property, the person taking a client into custody
shall take reasonable precautions to preserve and safeguard personal property. (§5156)
C. At the time a person is first detained, the person who makes the detention must provide
the following advisement, orally, which is to be noted on the 5150 form. The
information is to include the following:
My name is I am a (peace officer, mental
health professional, doctor, nurse, etc) with (name of agency, hospital). You are
not under criminal arrest, but I am taking you (transferring you) for examination
by mental health professionals at (name of Designated Facility). You will be told
your rights by the mental health staff.
If the person is taken into custody at his or her residence, the person must also
include the following: "You may bring a few personal items with you which I
will have to approve. You may make a telephone call and/or leave a note to tell
you friends and/or family where you have been taken".
D. The 72 hour hold under W&I Code 5150 begins with the initiation of time and date of
the "Application for 72-Hour Detention for Evaluation and Treatment", and allows for
evaluation and treatment up to 72 hours.
1. If in the judgment of the professional staff, at the Designated Facility, a person can
be properly served without being detained under §5150, the person shall be
provided evaluation, crisis intervention, or other inpatient or outpatient services on
a voluntary basis.
2. A person admitted to a Designated 5150 Facility can be, released before 72 hours
have elapsed only if, the psychiatrist responsible for the person's treatment
believes, based on personal observations, that the person no longer requires
Implementation of Welfare and Institutions Code Section 5150 Page 6 of 8
Contra Costa County POLICY NO. 714
Health Services Department
Menta!Health Division Review Date: December 2010
POLICY: Date Approved: December 3, 2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
evaluation or treatment. In situations in which both a psychiatrist and psychologist
have conducted an evaluation and collaborated on the treatment, either may
authorize release of the person from the hold, after consulting with one another.
(§5152(a))
E. Consumers Requiring 5150 in the Field (when in Contra Costa County)
1. It may' be determined that while the client is exhibiting acute symptoms, the
practitioner's relationship with the client is such that the practitioner feels safe in
transporting the client to the local. Designated 5150 Facility at either CCRMC-PES
or John Muir Behavioral Health (with prior arrangement). The 5150 Hold status
will be determined once at the.facility. This is to be done in accordance with
Supervisor and Clinic Site procedures.
2. If it is determined that a client requires a 5150 hold AND the client may or may not
have behavioral control, the police should be called to assist to ensure safety and
provide transportation, usually be calling AMR for transport to CCCRMC-PES.
F. Consumers Requiring 51.50 with an Emergent Medical Condition
1. At times clients placed on a W&I Code 5150 by law enforcement are routed to the
nearest Emergency Department for medical evaluation, rather than being
transported directly to a 5150 Designated Facility. In these cases, the client is
considered to be detained under Section 5150 and in transit to a designated 5150
facility after medical clearance.
2. When a consumer on a W&I Code 5150 hold is first transported to an Emergency
Room for medical clearance and it is determined that the consumer's physical
condition requires admission to an inpatient medical unit, the 51.50 hold is
considered to be void upon hospital admission.
3. Local Hospitals and Kaiser Medical Centers who have entered into a Memorandum
of Understanding between the Local Hospital and the Mental Health Director have
Designated Health Professionals who may initiate a"5150" at the Hospital or Clinic
at which they are designated,and in affiliation with.
4. For those Local Hospitals that have not entered into an agreement through the
Memorandum of Understanding with the Mental Health Director, the hospital may
determine that the patient is in need of a 5150 Hold, and use the Health & Safety
1799.111 to hold the patient up to 24 hours (effective .tan. 1, 2008) while seeking
psychiatric placement, and have law enforcement place the patient, on the 5150
Hold for transport to the Designated 5150 Facility.
Implementation of Welfare and Institutions Code Section 5150 Page 7 of!
Contra Costa County POLICY NO. 714
Health Services Department
Mental Health Division Review Date:December 2010
POLICY: Date Approved: December 3,2007
IMPLEMENTATION OF WELFARE AND
INSTITUTIONS CODE SECTION 5150
Health & Safety Code §1799.111 provides that a hospital is not subject to liability
for detaining a person, or for the actions of the person following release from the
hospital., if the following conditions exist: 1) The person cannot be safely released
from the hospital because, in the opinion of the treating physician and surgeon, the
person, as a result of a mental disorder presents a danger to himself or herself, or
others, or is gravely disabled; 2)The hospital staff or treating physician and surgeon
have made, documented, repeated unsuccessful efforts to find appropriate mental
health treatment for the person; and 3) The person is not detained beyond eight (8)
hours.
It is possible to detain an individual under H&S Code 1799.111, and use the W&I
Code 51.50 for the purpose of transport to a Designated 5150 Facility. The amount
of time the individual is detained under H&S Code 1799.11.1 is deducted from the
72 hours allowed for the psychiatric evaluation and treatment.
G. All rights and procedural protection of clients are to be strictly adhered to as outlined
in the Welfare and Institutions Code, in state and federaljudicial decisions interpreting
these statutes, and all other federal and state statutes and regulations, including
reporting obligations.
Implementation of Welfare and Institutions Code Section 51 SO Page 8 of 8
x"Instructions on Completing Application Fields.
State of California-Health and Human Services Agency Department of Mental Health
APPLICATION FOR 72 HOUR DETENTION DETAINMENT ADVISEMENT
FOR EVALUATION AND TREATMENT My name is
MH 302(Rev.08/04)Front
I am a(Peace Officer,etc.)with(Name of Agency).
Confidential Client/Patient Information You are not under criminal arrest,but I am taking you
See California WIC Section 5328 and for examination by mental health professionals at
HIPAA Privacy Rule 45 C.F.R.§164.508 (Name of Facility).
Welfare and Institutions Code (WIC), Section 5157, requires that each person You will be told your rights by the mental health staff.
when first detained for psychiatric evaluation be given certain specific information If taken into custody at his or her residence,the
orally, and a record be kept of the advisement by the evaluating facility. person shall also be told the following information in
_ __ ;t_:r•., substantially the following form;
❑ Advisement Complete Advisement Incomplete You may bring a few personal items with you which I
will have to approve. You can make a phone call
Good Cause for Incomplete Advisement IF APPLICABLE and/or leave a note to tell your friends and/or family
where you have been taken.
Advisement Completed By Position Date
NAME OF ADVISOR
To: EVALUATING FACILITY
Application is hereby made for the admission of PERSON'S NAME
Residing at PERSON'S HOME ADDRESS California, for 72-
hour treatment and evaluation pursuant to Section 5150, (adult) et seq. or Section 5585 et seq. (minor), of the WIC. If a
minor, to the best of my knowledge, the legally responsible party appears to be/ is: (Circle one) Parent; Legal Guardian;
Juvenile Court as a WIC 300; Juvenile Court as a WIC 601/602; Conservator. If known, provide names, address and
telephone number:
The above person's condition was called to my attention under the following circumstances: (see reverse side for definitions)
1. How the person and situation were brought to your attention.
2. Description of alleged behaviors or situation.
3. Relevant recent factors(prior hospitalization,under psychiatrist's care,dangerous or destructive behaviors.)
The following Intormatlon has peen estaoisnea: (urease give suniclently aetauea Intormatlon to support the pellet tnat the person
for whom evaluation and treatment is sought is in fact a danger to others, a danger to himself; herself and/or gravely disabled.)
1. Brief description of person.
2. Observable behavior and or"quotes"of person's statements.
3. Note any other justification for involuntary evaluation.
Based up on the above information it appears that there is probable cause to believe that said person is, as a result of mental
rficnrrfar• (CHECK APPROPRIATE BOX)
❑ A danger to himself/herself. ❑ A danger to others. u Gravely disabled adult. ❑ Gravely disabled minor.
Signature,title and badge number of peace officer, member of attending staff of evaluation facility or person Date Phone
designated by county, SIGNATURE&PRINT LAST NAME TITLEBADGE NUMBER Time
Name of Law Enforcement Agency or Evaluation Facility/Person Address of Law Enforcement Agency or Evaluation Facility/Person
NAME OF AGENCY AGENCY ADDRESS
I /
❑ vveapon was contiscafea ano cietained person notified of procedure for return of weapon pursuant to Section 8102 WIC.
(officer/unit&phone#)
NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY
NOTIFICATION OF PERSON'S RELEASE FROM AN EVALUATION AND TREATMENT FACILITY IS REQUESTED BY THE REFERRING PEACE
OFFICER BECAUSF-
❑ Person has been referred under circumstances in which criminal charges might be filed pursuant to Sections 5152.1 and 5152.2 WIC.
Notify(officer/unit&telephone#)
❑ Weapon was confiscated pursuant to Section 8102 WIC.
Notify(officer/unit&telephone#)
SEE REVERSE SIDE FOR INSTRUCTIONS