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Dle AGE SEX ADDRESS NAME OF COUNTY PROGRAM NAME OF BSU BSU NUMBER NAME OF FACILITY ADMISSION DATE ADMISSION NUMBER INSTRUCTIONS 1. Part I must be completed by the person who believes the patient is in need of treatment If this person is not a physician, police officer, the County Administrator or his delegate, he or she must request authorization or a warrant through the County Administrator. 2. If the authorization or a warrant through the County Administrator is required, call o.

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