Clinical Certificate {PCM 208}

In the matter of First, middle, and last name þ en-USTO THE EXAMINER: The following is a statement that must be read to the individual before proceeding with any questions.en-USI am authorized by law to examine you for the purpose of advising the court if you have a mental condition en-USwhich needs treatment and whether such treatment should take place in a hospital or in some other place. en-USI am also here to determine if you should be hospitalized or remain hospitalized before a court hearing is en-USheld. I may be required to tell the court what I observe and what you tell me. þ 1. þ I am a þ þ psychiatrist. þ þ licensed psychologist. þ þ physician. 2. þ I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination. 3. þ I further certify that I, en-USName (type or print)en-US , personally examined en-USPatient þ at en-USName and address where examination took place þ on þ en-USDateen-US starting at en-USTimeen-US and continuing for en-US en-US minutes. en-US en-USen-USwith other information which underlie your conclusion. en-USIndicate the source of any information not personally known or en-USobserved.en-USen-USperson requiring treatment or in need of hospitalization. 4. þ My determination is that the person is þ þ þ reality, or ability to cope with the ordinary demands of life). þ þ not mentally ill. þ 5. þ (if applicable) The person has þ þ convulsive disorder. þ þ alcoholism. þ þ other drug dependence. þ þ þ mental processes weakened by reason of advanced years. þ þ other (specify): en-US 6. þ My diagnosis is: en-US 7. þ Facts serving as the basis for my determination are: en-US þ en-US þ en-US þ þ en-US American LegalNet, Inc. www.FormsWorkFlow.com File No. 8. þ Explain in the space below the facts which lead you to believe that future conduct may result in en-US(check applicable box) þ þ þ þ Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near þ þ þ þ þ Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near þ þ þ c. þ inability to attend to basic physical needs. Facts: þ Therefore, I believe that the examined person, as a result of mental illness, is unable to attend to those basic physical þ needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future þ and has demonstrated that inability by failing to attend to those basic physical needs. þ þ d. þ inability to understand need for treatment. Facts: þ Therefore, I believe that the examined person, as a result of mental illness, is so impaired by that mental illness and þ whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to þ voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent þ þ mental harm to himself/herself or others. 9. þ I conclude the individual þ þ is þ þ is not þ a person requiring treatment. 10. þ (optional) I recommend þ þ hospitalization þ þ assisted outpatient treatment þ as follows: en-US þ en-US en-US .en-USI certify that I am a person authorized by law to certify as to the individual's mental condition. I am not related by blood or en-USen-USen-USme and that its contents are true to the best of my information, knowledge, and belief. en-USDate þ en-USTime of signing þ en-USSignature þ en-USPrint or type name and business telephone no. American LegalNet, Inc. www.FormsWorkFlow.com