EMERGENCY APPLICATION FOR INVOLUNTARY COMMITMENT WITH CERTIFICATION TO

__________________________________ Local Mental Health Authority

_______________, 20____ To The Director: I, ___________________________residing at _________________________________, State of ____________, hereby request the temporary, involuntary commitment of ___________________________ to _____________________________. Proposed Patient

Local Mental Health Authority

I believe that the said proposed patient is likely to cause serious injury to himself or others if not immediately restrained and that the individual’s condition or circumstances which lead to this belief are as follows:____________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ Names and addresses of persons to be notified of placement into custody of local mental health authority: Guardian:_____________________________________________________________________ Address

Phone

Adult Family:__________________________________________________________________ Address

Phone

Other:_______________________________________________________________________ Address

Phone

____________________________ Applicant Signature

____________________________ Relationship to proposed patient

DSA&MH Form 34-1, Revised 2015 (Page 1 of 2 – print on light blue paper or with a light blue border)

Utah Code Annotated 62A-15-629(1) 2002

CERTIFICATE FOR EMERGENCY COMMITMENT TO ___________________________________ Local Mental Health Authority I, __________________________, do hereby certify that I am a physician licensed under the laws of the State of Utah to practice medicine, or a medical officer of the United States Government in the State of Utah in the performance of my official duties, or a designated examiner appointed by the Division of Substance Abuse and Mental Health* and that I have examined _________________________, within a three-day period preceding this Proposed Patient

certification and am of the opinion that the proposed patient is mentally ill and, because of his mental illness, is likely to injure himself or others if not immediately restrained. The pertinent data that I have obtained is as follows:_____________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

Dated this ______ day of ____________________, 20________. ____________________________ *Cross out terms not applicable

Signature

Title

Instructions: An adult may be temporarily, involuntarily committed to a local mental health authority upon (I) written application by a responsible person who has reason to know, stating a belief that the individual is likely to cause serious injury to himself or others if not immediately restrained, and stating the personal knowledge of the individual’s condition or circumstances which lead to that belief; and (ii) a certification by a licensed physician or designated examiner stating that the physician or designated examiner has examined the individual within a three-day period preceding that certification, and that he is of the opinion that the individual is mentally ill and, because of his mental illness, is likely to injure himself or others if not immediately restrained. A person committed under this section may be held for a maximum of 24 hours, excluding Saturdays, Sundays, and legal holidays. At the expiration of that time period the person shall be released unless application for involuntary commitment has been commenced pursuant to Section 62A-15-631. UCA 62A-15-629

DSAMH Form 34-1, Revised 2015 (Page 2 of 2 – print on light blue paper or with a light blue border)

Utah Code Annotated 62A-15-629 (2002)

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