DELAWARE HEALTH AND SOCIAL SERVICES Division of Substance Abuse and Mental Health 1901 N. Dupont Highway, New Castle, DE 19720 Phone: (302) 255-2700 CERTIFICATE FOR INVOLUNTARY ADMISSION OF PATIENT TO DELAWARE PSYCHIATRIC CENTER AND/OR CERTIFIED TREATMENT FACILITY PURSUANT TO DELAWARE CODE CHAPTER 50, TITLE 16 Title 16, Section 5003, Delaware Code 5003, Provisional Hospitalization by Psychiatrist’s Certification. No person shall be involuntarily admitted to the hospital as a patient except pursuant to the written certification of a psychiatrist that based upon the psychiatrist’s examination of such person, such person suffers from a disease or condition which required him to be observed and treated at a mental hospital for his own welfare and which either renders such person unable to make responsible decisions with respect to his hospitalization, or poses a present threat, based upon manifest indications, that such person is likely to commit or suffer serious harm to himself or others or to property, if not given immediate hospital care and treatment. The certificate shall state with particularity the behavior and symptoms upon which the psychiatrist’s opinion is based, shall include (where available) the name and address of the spouse or other nearest relative or person of close relationship to the alleged mentally ill person, and shall state that such person is not willing to accept hospital care and treatment on a voluntary basis or that he is incapable of voluntarily consenting to such care and treatment. PART 1. (To be completed by certifying psychiatrist) The undersigned certifies that he is a physician licensed to practice medicine in the State of Delaware and specializing in the field of psychiatry and he has examined: Name of Patient Address of Patient Age:___________ Date of Birth:_______________ Religion:_________________________ Patient’s spouse, other nearest relative, or person of close relationship: Name Relationship Address Telephone Number As a result of my examination of the patient, I am of the opinion that the patient suffers from a disease or condition which requires him (or her) to be OBSERVED and TREATED at a MENTAL HOSPITAL for his (or her) own welfare. The disease or condition: ______ renders the patient unable to make responsible decisions with respect to his hospitalization ______ poses a present threat, based upon manifest indication, that the patient is likely to commit or suffer serious harm: ________ to himself (or herself) ________ to others ________ to property The behavior and symptoms upon which my opinion is based are as related to me by others (state whom): As observed during my examination of the patient: 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. Name of family physician or psychiatrist____________________________________________________ Physical conditions, which require immediate or continuous attention: Signed:________________________________________, M.D. Physician Specializing in the Field of Psychiatry _________________________________________________, M.D. Name Printed Address:_______________________________________________________________________________________ Date:_______________________ Time:_____________________ AM. PM. PART 2. (to be completed by hospital staff after provisional admission) NOTIFICATION OF RIGHTS I certify that I have this day delivered to, a copy of 16 Del. C., Sec. 5161, Rights of a Patients in Hospitals for the Mentally Ill, and other rights set forth in Title 16, Delaware Code. Received:________________________________ Name:______________________________ Patient’s Signature OR Title:__________________________________ Patient refused to sign_____________________ Date:_______________________________ CERTIFICATION OF MENTAL ILLNESS AND NEED FOR TREATMENT (to be completed only when provisional admission was made on the certificate of a psychiatrist not employed by the Delaware Psychiatric Center) I have examined the Psychiatrist’s Certificate for Involuntary Admission of Patient to Delaware Psychiatric Center in the case of : Name of Patient And have personally conducted a psychiatric examination of the patient; the behaviors and symptoms observed during my examination of the patient are as follows: In my opinion, the patient: IS / IS NOT a mentally ill person requiring hospital confinement. (Circle One) DOES / DOES NOT require treatment pending judicial proceedings under provisions of 16 Del. C. Ch 50. (Circle One) IS / IS NOT capable of waiving procedural right including retention of counsel, retention of psychiatrist (Circle One) or other qualified medical expert to testify in his behalf, and the hearing in court. _________________________________________ ______________________________________________ Signature of Examining Psychiatrist Date CERTIFICATION OF FINANCIAL ABILITY TO RETAIN PRIVATE MEDICAL, PSYCHIATRIC AND / OR LEGAL REPRESENTATION: Based upon financial information obtained from Name of Informant Relationship I am of the opinion that _____________________________________________________________________ Patient’s Name _______ Can afford to retain legal counsel. _______ Cannot afford to retain legal counsel. _______ Can afford to retain a psychiatrist or other qualified medical expert. _______ Cannot afford to retain a psychiatrist or other qualified medical expert ______________________________________ ______________________________________ Name of Guarantor (If private legal, medical or Street Psychiatric representation is to be retained) __________________________________________ City State Zip Code _________________________________________ Telephone Number Being unable to afford private representation, the patient respectfully prays the court to appoint and assume financial responsibility for the services of _________ Legal Counsel ________ Psychiatrist or other qualified medical expert _______________________________________ Financial Resources Examiner ___________________________________________ Date APPROVED: _______________________________________ Hospital Official ___________________________________________ Date