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Certification Of Qualified Health Professional Involuntary Treatment (Alcohol And Drug Abuse) AOC-703A - Kentucky
| Certification Of Qualified Health Professional Involuntary Treatment (Alcohol And Drug Abuse) Form. This is a Kentucky form and can be used in Involuntary Hospitalization Statewide . |
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AOC-703A Doc.Code:CIT Case No.____________________ Rev.10-06 Page1of3 District Court_______________________ CommonwealthofKentucky CertifiCation of Qualified CourtofJustice County______________________ www.courts.ky.gov HealtH Professional KRS222 involuntary treatment (alCoHol/drug abuse) IN THE INTEREST OF: RESPONDENT___________________________________________________________________________________ 1. Comes the Affiant, ___________________________________________________________________________________, and states that he/she is a Qualified Health Professional as defined in KRS 222, and he/she is, [ ] A Qualified Mental Health Professional as defined in KRS 202A.011; and/or [ ] An Alcohol and Drug Counselor certified under KRS Chapter 309; and/or [ ] A Physician, licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the performance of official duties. Affiant further states that he/she examined the above-named Respondent and based on that examination, in his/her professional opinion, the Respondent [ [ [ [ ] ] ] ] does, does, does, can, [ [ [ [ ] ] ] ] does not suffer from alcohol and/or other drug abuse, does not present a danger to self, family or others, or there does not exist a substantial likelihood of such a threat in the near future; and cannot reasonably benefit from treatment. 2. 3. The facts that support Affiant's belief that Respondent does suffer from alcohol and/or other drug abuse: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 4. The facts that support Affiant's belief that Respondent is a danger or threat of danger to self, family or others, or that there exists a substantial likelihood of such a threat in the near future: ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 5. Diagnostic impressions:________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com AOC-703ADoc.Code:CIT Rev.10-06 Page2of3 6. Other factors contributing to need for treatment: _____________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 7. Goal of treatment and recommendation for treatment: ________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ ___________________________________________________________________________________________________ 8. Date examination was performed: __________________________ Further, Affiant sayeth naught. ____________________________ Date ______________________________________________ Signature of QHP ______________________________________________ Name of QHP (Please Print) ______________________________________________ Title of QHP ______________________________________________ Name of Treatment Facility of QHP SubSCRIbeDandSwORnTObeforemeonthis_______dayof_____________________________,2_______. MyCommissionexpires: ______________________________ ____________________________________________ name/Title ____________________________________________ County,Kentucky NOTE: A separate Certification of Qualified Health Professional (AOC 703A) must be filed with the Court by each of the two (2) QHPs named in the Hearing, Examination and Appointment of Counsel Notice and Order (AOC-701A) not later than twenty-four (24) hours prior to the hearing date set out in AOC-701A, unless another hearing date is ordered by the Court. See page 3 for more information on Qualified Health Professionals. Petitioner is responsible for all costs of examination. American LegalNet, Inc. www.FormsWorkFlow.com AOC-703A Doc Code: CIT Rev. 10-06 Page 3 of 3 CERTIFICATION Note: Iffor72-hourinvoluntarytreatment,thiscaserequiresaCertificationtobecompletedand filedbyONE"QualifiedHealthProfessional." Iffor60/360dayinvountarytreatment,thiscaserequiresaCertificationtobecompletedand filedbyeachofTWO"QualifiedHealthProfessionals,"oneofwhommustbealicensed physician. Criteriaforeachprofessionalarelistedbelow "Qualifiedhealthprofessional"has the same meaning as qualified mental health professional in KRS 202A.011, except that it also includes an alcohol and drug counselor certified under KRS Chapter 309. "Qualifiedmentalhealthprofessional"underKRS202A.011(12)means: a. A physician licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the performance of official duties. b. A psychiatrist licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the practice of official duties, who is certified or eligible to apply for certification by the American Board of Psychiatry and Neurology, Inc. c. A psychologist with the health service provider designation, a psychological practitioner, a certifiedpsychologist, or a psychological associate, licensed under the provisions of KRS Chapter 319. d. A licensed registered nurse with a master's degree in psychiatric nursing from an accredited institution and two (2) years of clinical experience with mentally ill persons; or a licensed registered nurse, with a bachelor's degree in nursing from an accredited institution, who is certified as a psychiatric and mental health nurse by the American Nurses Association and who has three (3) years of inpat
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