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Ohio Department of Mental Health Application for Emergency Admission In Accordance with Sections 5122. 01 and 5122. 10 ORC DMH-0025 TO The Chief Clinical Officer of Regional Psychiatric Hospital - RPH/Facility Name Date/Time The undersigned has reason to believe that Name of Person to be Admitted Is a mentally ill person subject to hospitalization by court order under division B Section 5122. 01 of the Revised Code i*e* this person 1 Represents a substantial risk of physical harm to self as manifested by evidence of threats of or attempts at suicide or serious self-inflicted bodily harm other violent behavior evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm or other evidence of present dangerousness evidence that the person is unable to provide for and is not providing for the person s basic physical needs because of the person s mental illness and that appropriate provision for those needs cannot be made immediately available in the community or 4 Would benefit from treatment in a hospital for his mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or himself* Therefore it is requested that said person be admitted to the above named facility. STATEMENT OF BELIEF Must be filled out by one of the following a psychiatrist licensed clinical psychologist licensed physician health or police officer sheriff or deputy sheriff* Statement shall include the circumstances under which the individual was taken into custody and the reason for the person s belief that hospitalization is necessary. The statement shall also include a reference to efforts made to secure the individual s property at his residence if he was taken into custody there. Every reasonable and appropriate effort should be made to take this person into custody in the least conspicuous manner possible. Original - Medical Record Copy - Suspense File DMH-0025 Rev* 01/11 Page 1 of 2 APPLICATION FOR EMERGENCY ADMISSION DMH-MedR-1030 Signature Title/Position/Badge or License No* Place of Employment OR LICENSED CLINICAL PSYCHOLOGIST IF APPLICABLE Place of Observation e*g* community mental health center general hospital office emergency facility Approved Title Yes No Signature of Chief Clinical Officer. 01 and 5122. 10 ORC DMH-0025 TO The Chief Clinical Officer of Regional Psychiatric Hospital - RPH/Facility Name Date/Time The undersigned has reason to believe that Name of Person to be Admitted Is a mentally ill person subject to hospitalization by court order under division B Section 5122. 01 of the Revised Code i*e* this person 1 Represents a substantial risk of physical harm to self as manifested by evidence of threats of or attempts at suicide or serious self-inflicted bodily harm other violent behavior evidence of recent threats that place another in reasonable fear of violent behavior and serious physical harm or other evidence of present dangerousness evidence that the person is unable to provide for and is not providing for the person s basic physical needs because of the person s mental illness and that appropriate provision for those needs cannot be made immediately available in the community or 4 Would benefit from treatment in a hospital for his mental illness and is in need of such treatment as manifested by evidence of behavior that creates a grave and imminent risk to substantial rights of others or himself* Therefore it is requested that said person be admitted to the above named facility.