SOP 508.25-att-5: Involuntary Psychiatric Hospital Admission Review (Form M65-01-05)

SOP 508.25
Attachment 5

8/2/22

MH Involuntary Psychiatric Hospitalization Due Process Committee
Involuntary Psychiatric Hospital Admission Review

Offender’s Information:

Offender’s Name: __________________________________ ID#: _____________________

Referring Facility: ____________________________________ Date of Referral: ___________

Offender’s Advocate (name/title): _________________________________________________

Offender’s Attorney (name if present): _____________________________________________

State's Advocate (name/title): ___________________________________________________

Witness(es) (Name/title of presenter questioned):

(name/title): _________________________________________________________

(name/title): _________________________________________________________

Committee Members:

(name/title): _______________________________________________________

(name/title): _______________________________________________________

(name/title): _______________________________________________________

Hearing Officer: __________________________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Mental Health Committee Member: ______________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Medical Committee Member: _____________________________________________________

Signature/Title: _________________________________________ Date/Time: __________

Offender Name/Signature: ___________________________________ I.D. #: _____________

Form no. M65-01-05 Page 1 of 2

Retention Schedule: Completed forms will be given to the Psychiatric Hospital (original), a copy will be given to the
offender, and a copy will be 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 5

8/2/22

|Criteria|Yes|No|
|---|---|---|
|
1.
The offender is mentally ill, that is, has a disorder of thought or
mood which significantly impairs judgment, behavior, capacity
to recognize reality or ability to cope with the ordinary demands
of life AND the offender presents a substantial risk of imminent
harm to themselves or others as manifested by recent overt acts
or recent expressed threats which present a probability of injury
to themselves or to others.|
|
|
|
2.
The offender is mentally ill, that is, has a disorder of thought or
mood which significantly impairs judgment, behavior, capacity
to recognize reality or ability to cope with the ordinary demands
of life AND the offender is unable to care for their own physical
health and safety as to create an imminently life endangering
crisis.
|
|
|

Document Committee Reasons for the above decisions :

_Note: If criteria #1 and/or #2 are marked yes, then involuntary psychiatric hospitalization is justified._

/__________________________
Hearing Officer Signature Date

Form no. M65-01-05 Page 2 of 2

Retention Schedule: Completed forms will be given to the Psychiatric Hospital (original), a copy will be given to the
offender, and a copy will be 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.