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 ...
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