SOP 508.25-att-1: Certificate of Referral for Emergency Admission (Form M65-01-01)

Division:
Mental Health Services
Effective Date:
August 2, 2022
Topic Area:
Mental Health Evaluations/Screenings/Treatment
PowerDMS:
View on PowerDMS
Length:
136 words

Summary

This form is used to document and process emergency psychiatric hospital admissions for incarcerated individuals who require immediate mental health intervention. The original certificate is submitted to the psychiatric hospital, with copies retained in both the offender's mental health file and medical file. Completed forms are retained for 10 years following the end of the offender's need for mental health services or upon sentence completion.

Key Topics

  • emergency admission
  • psychiatric hospital referral
  • mental health crisis
  • emergency mental health evaluation
  • inmate mental health
  • certificate of referral
  • psychiatric emergency
  • mental health documentation
  • emergency psychiatric care
  • form M65-01-01

Full Text

SOP 508.25
Attachment 1
8/2/22

Form no. M65-01-01 Page 1 of 2

Retention Schedule: Completed forms shall be given to the Psychiatric Hospital (original), a copy placed in the offender’s mental health

file (section 5) and medical file (section 5). At the end of the offender’s need for mental health services and/or sentence, the mental
health file will be placed within the offender’s health record and retained for 10 years.

SOP 508.25
Attachment 1
8/2/22

Form no. M65-01-01 Page 2 of 2

Retention Schedule: Completed forms shall be given to the Psychiatric Hospital (original), a copy placed in the offender’s mental health

file (section 5) and medical file (section 5). At the end of the offender’s need for mental health services and/or sentence, the mental
health file will be placed within the offender’s health record and retained for 10 years.

Attachments (5)

  1. Certificate of Referral for Emergency Admission (Form M65-01-01) (136 words)
  2. Certificate of Mental Condition (Form M65-01-02) (68 words)
  3. Emergency Admission Rights of Offenders (Form M65-01-03) (690 words)
  4. Notification of Involuntary Hospitalization Due Process Committee Hearing (181 words)
  5. Involuntary Psychiatric Hospital Admission Review (Form M65-01-05) (385 words)
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