STATE OF UTAH APPLICATION FOR VOLUNTARY ADMISSION TO LOCAL MENTAL HEALTH AUTHORITY

TO THE DIRECTOR: I, County of:

, residing at:

,

, State of Utah, Date of Birth_____________*, hereby

apply for voluntary admission to

Local Mental Health Authority

.

_________________________________________ Signature of Patient or Legal Guardian

Date

_________________________________________ Witness

Date

_________________________________________ Witness

Date

INSTRUCTIONS: “A local mental health authority or its designee may admit to that authority, for observation, diagnosis, care, and treatment any individual who is mentally ill or has symptoms of mental illness and who, being 18 years of age or older, applies for voluntary admission.” UCA 62A-15-625(1)(2002) *Persons under the age of 18 may be committed to a local mental health authority only in accordance with the provisions set forth in UCA 62A-15-701. DSAMH Form 35-1, Revised 2012

35-1 Application for Voluntary Admission to Local Mental Health ...

... a local mental health authority only in accordance with the provisions set forth ... 35-1 Application for Voluntary Admission to Local Mental Health Authority.pdf.

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