West Virginia > Statewide > Circuit Court > Mental Hygiene
Certificate Of Licensed Examiner SCA-MH-904 - West Virginia
|Certificate Of Licensed Examiner Form. This is a West Virginia form and can be used in Mental Hygiene Circuit Court Statewide .||
|Get this form for FREE as a print-only pdf|
IN THE CIRCUIT COURT OF IN RE: The Involuntary Hospitalization, Treatment Compliance, or Temporary Probable Cause of: COUNTY, WEST VIRGINIA Case No.: -MH(TCO/TPC) - RESPONDENT (NAME OF PATIENT) CERTIFICATE OF LICENSED EXAMINER West Virginia Code: §§ 27-5-2, 3 & 4 AND §27-5-11 Instructions: All pages of this certificate must be fully completed. I, [Print Name of Licensed Physician, Licensed Psychologist, Court authorized Licensed Independent Clinical Social Worker, or Court authorized Licensed Advanced Nurse Practitioner with Psychiatric Certification or Physician Assistant], do hereby certify and state as follows: I have personally observed and examined Respondent] whose identifying information is believed to be, DATE OF BIRTH HAIR COLOR SEX RACE RESPONDENT'S LAST KNOWN ADDRESS: ; HEIGHT ; WEIGHT ; HAIR LENGTH ; EYE COLOR ; ; ; . [full name of PLACE OF BIRTH [state or country] THE RESPONDENT IS: A RESIDENT OF on this date and my findings are as follows: Date of Examination: Place of the Examination: [City], Time: [Location], [County], West Virginia. COUNTY, STATE. INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner American LegalNet, Inc. www.FormsWorkFlow.com Page 1 of 10 Case No.: -MH(TCO/TPC) - FINDINGS 1. I find there is reason to believe the Respondent [initial the appropriate items below] IS mentally ill IS addicted IS NOT mentally ill IS NOT addicted [If the individual is being certified for addiction, initial the following if it is applicable] I recommend that the individual be closely monitored because of the reasonable likelihood that withdrawal or detoxification will cause significant medical complications. 2. I further find that the Respondent [initial one] IS IS NOT likely to cause harm to himself/herself or others DUE TO HIS/HER MENTAL ILLNESS OR ADDICTION. 3. If the selection in question 2 above is "IS," it is based on one or more of the following: [check all appropriate items from the list of five items below and detail the specific facts under each checked item] The individual has inflicted or attempted to inflict bodily harm on another: [describe] The individual, by threat or action, has placed others in reasonable fear of physical harm to themselves: [describe] The individual, by action or inaction, has presented a danger to others in his or her care: [describe] The individual has threatened or attempted suicide or serious bodily harm to himself or herself: [describe] The individual is behaving in such a manner as to indicate that he or she is unable, without supervision and the assistance of others, to satisfy his or her need for nourishment, medical care, shelter or selfprotection and safety so that there is a substantial likelihood that death, serious bodily injury, serious physical debilitation, serious mental debilitation or life-threatening disease will ensue unless adequate treatment is afforded: [describe] INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 10 Case No.: 4. -MH(TCO/TPC) - [You must complete this question if you have indicated "mental illness" in question 1.] The specific, CURRENT, symptoms and behavior I HAVE OBSERVED on which my finding of mental illness is based are: Any other specific symptoms and behavior on which my finding of mental illness is based are: INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 10 Case No.: 5. -MH(TCO/TPC) - [You must complete this question if you have indicated "addiction" in question 1.] The specific manifestations which have occurred WITHIN 30 DAYS prior to the filing of the petition/ application is this action upon which my finding of addiction is based are: [Check all that apply; you MUST check at least one.] Recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home: [specify] Recurrent substance use in situations in which it is physically hazardous: [specify] Recurrent substance-related legal problems: [specify] Continued substance use despite knowledge of having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance: [specify] Other specific symptoms and behavior on which my finding of "addiction" is based are: 6. I received information relevant to this evaluation from the following sources: [Consult as many sources as possible; check all that apply] Family Members Other: [list] American LegalNet, Inc. www.FormsWorkFlow.com Respondent Petitioner Medical Record Physician INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner Page 4 of 10 Case No.: 7. -MH(TCO/TPC) - Prior history of behavior health services in the following settings (add # for clarity): Type of Treatment Outpatient Yes No Unknown Compliant Non-Compliant Date(s) Voluntary Inpatient or Residential Treatment Previous Commitment(s) If "no" marked in outpatient, or voluntary inpatient or residential treatment above, why are these less restrictive alternatives not being attempted at this time? [explain] 8. List all medications currently taking, or prescribed and should be taking: Dosage: Duration: Name of Medication: 1. 2. 3. 4. 5. 9. Are there any acute medical conditions that require immediate attention? [Check one] If "Yes," list the condition(s): Yes No 10. Is Medical Clearance Examination NECESSARY? [Check one] health facility? [Check one] Yes No Unknown Yes No Unknown If yes, has it been completed or arranged to be completed, prior to involuntary admission to a mental Medical Screening was completed at: Medical Screening arranged to be completed at: INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 10 Case No.: 11. -MH(TCO/TPC) - The results of my evaluation suggest the following factor(s) are present, or have been present in the past: [check all that apply] Factors General Information [check if yes, list date(s) when present] Ideation Plan Intent Other Prior History: [If yes, explain/give examples] Yes No Thoughts of Suicide Thoughts of Homicide Ideation Plan Intent Other Prior History: [If yes, explain/give examples] Yes No Head Injury/ Neurological Type(s): Chronic Medical Problems Type(s): Limitations to Support System Type(s): History of Legal Infractions Type(s); Explain: Past History of Harmful Behavior Type(s): INV 10 Rev. 09/13/2012 Certificate of Licensed Examiner American LegalNet, Inc. www.FormsWorkFlow.com Page 6 of 10 Case No.