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Certification By Peace Officer And Other Qualified Persons CC-DC 14 - Maryland

Certification By Peace Officer And Other Qualified Persons Form. This is a Maryland form and can be used in General Circuit-District Court Statewide .
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CERTIFICATION BY PEACE OFFICER I am a sheriff, deputy sheriff, State police officer, county police officer, municipal or other local police officer, or Secret Service agent who is a sworn special agent of the United States Secret Service or Department of Homeland Security authorized to exercise powers delegated under 18 U.S.C. § 3056. As to observed the evaluee or evaluee's behavior and, based on the (evaluee), I have personally observation or other information, have reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or others. Pursuant to Maryland Code, Health­General Article § 10-622, I have transported the evaluee to (emergency facility) for evaluation. Date and Time Peace Officer Department I.D. No. CERTIFICATIONS BY OTHER PERSON QUALIFIED UNDER HG § 10-622 AND PEACE OFFICER I am a physician, psychologist, clinical social worker, health officer or licensed clinical professional counselor, psychiatric nurse practitioner, (evaluee). Based on a licensed clinical nurse specialist in psychiatric and mental health nursing, clinical marriage and family therapist, designee of a health officer. I have examined the examination or other information, I have reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or others and, in accordance with Maryland Code, Health­General Article § 10-622, have completed the attached Petition for Emergency Evaluation and have requested a peace officer to take into custody and transport the evaluee to the nearest emergency facility for evaluation by a physician. The peace officer explained to me the serious nature, meaning, and content of the petition and I asked the officer to proceed. Date and Time Physician or other Qualified Person under HG § 10-622 License No. I have explained to the Petitioner the serious nature of the petition and the meaning and content of the petition. Date Peace Officer Department I.D. No. CC-DC 14 (Rev. 11/2008) American LegalNet, Inc. www.FormsWorkFlow.com
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