DELAWARE HEALTH AND SOCIAL SERVICES Division of Substance Abuse and Mental Health 1901 N. Dupont Highway, New Castle, DE 19720 Phone: (302) 255-2700 24 HOUR EMERGENCY ADMISSION FORM (Treatment shall not exceed 24 Hours) (Delaware Code: Title 16, Chapter 51, Section 5122 as Amended 7/92) STATEMENTS 1, 2, AND 3A MUST BE COMPLETED BEFORE THIS FORM IS PRESENTED TO THE ADMITTING PHYSICIAN: 1. STATEMENT OF COMPLAINT: I hereby certify that I have knowledge that _______________________________________________________________ (Name of person to be admitted) of________________________________________________________________________________________________ (Street address, city, state) appears to have a mental illness and is likely to be in danger of hurting him or herself, or others, and requires immediate care, treatment, or restraint. I certify this because: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ Additional Information: History of prior psychiatric hospitalizations: Yes______ No_______ Unknown___________ If yes, when and where was the most recent admission:__________________________________________ Prior or current substance abuse or psychiatric treatment: Yes _______ No_____Unknown___________ If yes, where, and therapist’s name and phone number:__________________________________________ Current substance abuse: Yes______ No________ Unknown_________ If yes, what and when last used:______________________________________________________________ Danger to self and others includes, but is not limited to, the following scenarios: * Expressing suicidal or homicidal thoughts with a plan and means to carry out the threat. * Inflicting or attempting to inflict serious bodily harm on themselves or others through overdose or physical means, and there is reasonable probability that such conduct will be repeated. * Experiencing delusions or thought disturbances that place the person in danger ,or puts others in danger. Relationship or other connection with person to be admitted:______________________________________________ Name and phone number of spouse or closest relative (if known) of person to be admitted:_____________________ Signature of person making complaint:_______________________________ Date and Time:____________________ Print Name: _____________________________________________ Phone:__________________________________ Address:__________________________________________________________________________________________ 2. STATEMENT OF PEACE OFFICER: I have taken _______________________________________________, with all reasonable promptness, to a physician licensed in the State of Delaware to practice medicine or surgery. Describe briefly the circumstances, and your observations about this person and their level of danger, to self or others:_______________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________ Signature of Officer:__________________________________ Title and Unit:________________________________ Print Name:_________________________________________ Date and Time:_______________________________ --------------------------------------------------------------------------------------------------------------------------------------- 3. STATEMENT OF EXAMINING PHYSICIAN: I certify that I am a physician licensed in the State of Delaware to practice medicine or surgery. I certify that I have evaluated______________________________________ Date: _________________ Time: _________________ Location of Evaluation:_______________________________________________________________________________ (COMPLETE A or B) A. I have personally examined this person and find that he/she has met the standards of “A person who has a mental illness and is likely to be in danger of hurting him or herself, or others, and to require immediate care, treatment, or restraint.” And further: _____ the patient is not willing to accept hospital care and treatment on a voluntary basis. _____ the patient is incapable of voluntarily consenting to hospital care and treatment. (Give a description of the behavior and symptoms) __________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________ (Please attach other forms or documents to support your findings) Physician Signature:_________________________________ Print Name:_____________________________________ (Physician must sign and print name) Physician’s Address and Phone Number: ________________________________________________________________ __________________________________________________________________________________________________ I have notified the nearest known relative that the person is being taken to:______________________________________ Yes_______ No________ (This form is to be forwarded to the receiving hospital with the transporting officer or designee) B. I find this person has NOT met the standards of “A person who has a mental illness and is likely to be in danger of hurting him or herself, or others, and to require immediate care, treatment, or restraint.” (Give a description of the behavior and symptoms) __________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ What if any disposition plans were provided to this person upon discharge: __________________________________________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ (Please attach other forms or documents to support your findings) Physician Signature:_________________________________ Print Name:_____________________________________ (Physician must sign and print name) Physician’s Address and Phone Number:_________________________________________________________________ __________________________________________________________________________________________________ I have notified the nearest known relative that the person has been released: Yes_______ No________ (Fax copy of completed form to DSAMH’s Eligibility and Enrollment Unit (302) 255-4416 ………………………………………………………………………………………………………………………………… 4. STATEMENT OF PHYSICIAN ADMITTING TO IN-PATIENT FACILITY: Nearest known relative notified: Yes_________ No___________ Comments:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ REQUEST FOR TRANSPORTATION REIMBURSEMENT FOR PERSONS TREATED UNDER A MENTAL HEALTH COMMITMENT (Delaware Code: Title 16, Chapter 51, Section 5122 (e) as Amended 6/06) “(e) The State Treasurer shall pay police officers, constables, sheriffs and deputy sheriffs for service as peace officers under this section at the rate of 31 cents for each mile necessarily traveled and a custody fee of $100 when transporting a mentally ill person from one county to another. Complaint No:_______________________________ Date, Time of Complaint:______________________________ Name of Dept/Troop#_______________________________________________________________________________ Address and Phone Number:_________________________________________________________________________ __________________________________________________________________________________________________ Patient Name:______________________________________________________________________________________ Date and Time of Transport:_________________________________________________________________________ Name of Transporting Officer: __________________________________ IBM#__________________________ Name of Second Officer:_________________________________________ IBM#_________________________ Client Transported: From:_____________________________________ To:________________________________________ # of miles______________________ Client Transported: From:_____________________________________ To:________________________________________ # of miles______________________ Total Miles:__________________@ $0.31 = $____________ Custody Fee ($100.00) = $____________ *(Custody fee is paid only when a person with a mental illness is transported from one county to another) Total Reimbursement Requested: = $____________ __________________________________________________________________________________________________ I hereby certify that the information on this Reimbursement Form is complete and accurate, and that the above-mentioned patient has been transported to the designated receiving facility in accordance with the Delaware Mental Health Commitment Code. Name of Officer Completing this Form:_______________________________________________________________ Signature:________________________________________ Title and Unit:___________________________________ Print Name:_______________________________________ Date and Time:__________________________________ Please mail this form at time of service to: Division of Substance Abuse and Mental Health Contracts Unit: Main Administration Building Herman Holloway Campus New Castle, Delaware 19720 5