CIRCUIT COURT DISTRICT COURT OF MARYLAND FOR City/County Court Address Located at In the Matter of Case No. PETITION FOR EMERGENCY EVALUATION (Maryland Code, Health General Article § 10-620 et seq.) The Petitioner, Name of Petitioner , requests that this Court order an emergency evaluation of and in support of this Petition states as follows: Name of Person to be evaluated (Evaluee) 1. Petitioner: Address Cell Phone/Pager # Home Phone Work Phone . If Petitioner is a physician, psychologist, clinical social worker, licensed clinical professional counselor, clinical nurse specialist in psychiatric and mental health nursing, psychiatric nurse practitioner, licensed clinical marriage and family therapist, or health officer or designee of a health officer who has examined the Evaluee, then the Petitioner's specialty is and the Petitioner's license number is . Relationship to or interest in Evaluee 2. Evaluee: Address DOB Sex Race Ht. Wt. Hair Eyes Complexion Other 3. If not Petitioner, name of spouse, child, parent, or other relative, or other individual interested in the Evaluee: Name Relationship Address Home Phone Work Phone 4. A petition for emergency evaluation of the Evaluee was filed previously on Date(s) and was granted denied. 5. The Evaluee has been hospitalized in the past at the following facilities: When When Where Where Diagnosis Diagnosis 6. The Evaluee currently is receiving psychiatric treatment from: Name Name Address Address Phone Phone 7. The Evaluee has been prescribed the following medication for his/her mental disorder: 8. The Evaluee is is not taking the medication as prescribed OR I do not know whether the Evaluee is taking medication as prescribed. 9. The Evaluee is demonstrating the following behavior that leads me to conclude that he/she currently has a mental disorder: (Attach additional sheet if necessary) 10. The Evaluee presents a danger to the life or safety of the Evaluee or others because: (Attach additional sheet if necessary) 11. The Evaluee has access to the following firearms/weapons: I solemnly affirm under the penalties of perjury that the contents of the foregoing paper are true to the best of my knowledge, information, and belief. Date Petitioner Fax E-mail American LegalNet, Inc. www.FormsWorkFlow.com CC-DC-013 (Rev. 7/2014) (front) TO THE PETITIONER: You may be required to appear before the Court. You have made the statements above under penalties of perjury. If an evaluation is ordered, it would be helpful if you could accompany the Evaluee to the emergency facility and provide facility authorities with all information that is pertinent to this Petition. A Petitioner who, in good faith and with reasonable grounds, submits or completes the Petition for Emergency Evaluation is not civilly or criminally liable for submitting or completing the Petition. ENDORSEMENT AND ORDER In the matter of the emergency evaluation of (Case No ), the Petitioner having presented to the Court and the Court having reviewed the Petition and considered all pertinent data presented, the Court: Finds probable cause to believe that the named individual (Evaluee) has shown the symptoms of a mental disorder and presents a danger to the life or safety of the Evaluee or others and, therefore, ORDERS that any peace officer take into custody and transport the Evaluee to the nearest emergency facility, for examination by a physician within six hours after arrival at the facility and, if in the physician's opinion necessary, for emergency care and treatment; provided that the facility may not keep the Evaluee for more than 30 hours under this Order but is not precluded from voluntary or involuntary admission in accordance with Maryland Code, Health-General Article. Denies the Petition, finding no probable cause. Date Judge ID Number A. Duties of Peace Officer 1. Caution to Petitioner. A peace officer shall explain to a physician, psychologist, clinical social worker, licensed clinical professional counselor, clinical nurse specialist in psychiatric and mental health nursing, psychiatric nurse practitioner, a licensed clinical marriage and family therapist, or a health officer or designee of a health officer, who presents a petition to the peace officer: a. the serious nature of the Petition; and b. the meaning and content of the Petition. 2. Delivery to Facility. A peace officer shall take an Evaluee to the nearest emergency facility if the officer has a petition that: a. has been endorsed by a court within the last 5 days; or b. is signed and submitted by a physician, psychologist, clinical social worker, licensed clinical professional counselor, clinical nurse specialist in psychiatric and mental health nursing, psychiatric nurse practitioner, a licensed clinical marriage and family therapist, or a health officer or designee of a health officer, or peace officer. 3. Documentation of Delivery. A peace officer shall complete a Return of Service by Peace Officer form (CC-DC 27) and have an agent for the emergency facility sign the form. 4. Remaining with Evaluee. a. After a peace officer takes an Evaluee to an emergency facility, the officer need not stay unless, because the Evaluee is violent, a physician asks the officer's supervisor to have the officer stay. b. A peace officer shall stay until the officer's supervisor responds to the request for assistance. 5. Return of Service. A peace officer shall file a completed Return of Service with the Court issuing the Endorsement and Order immediately after an Evaluee is delivered to an emergency facility or immediately after expiration of the five-day period for taking the Evaluee into custody. B Duty of Supervisor. A supervisor shall allow a peace officer to stay with a violent Evaluee. C. Duties of Emergency Facility 1. Documentation of Delivery. An agent of the emergency facility shall sign the Return of Service by Peace Officer form completed by a peace officer transporting an Evaluee to the facility. 2. Examination. If a physician asks that a peace officer stay, a physician shall examine the Evaluee as promptly as possible to determine whether the Evaluee meets the requirements for involuntary admission. In any event, a physician shall examine an Evaluee within six (6) hours after an officer brings the Evaluee to the facility. 3. Release or Admission. Promptly after an examination, an Evaluee shall be released unless the Evaluee: a. asks for voluntary admission; or b. meets the requirements for involuntary admission. 4.