Free MC-105 - Alaska

PEACE OFFICER/MENTAL HEALTH PROFESSIONAL APPLICATION FOR EXAMINATION (AS 47.30.705) Name of Potential Patient: Date and Time: Age: Sex: Race: Marital Status:

I hereby certify that probable cause exists under AS 47.30.705 to believe that the above-named individual is mentally ill and is: gravely disabled likely to cause serious harm to self others

of such immediate nature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700. Pertinent Information:

I am a: peace officer. psychiatrist / physician currently licensed to practice in the state of Alaska or employed by the federal government. clinical psychologist licensed by the state Board of Psychologist and Psychological Associate Examiners.

Signature of Peace Officer or Mental Health Professional Print Name Daytime Telephone Number Mailing Address City State Zip

NOTE: Pursuant to AS 47.30.705, any police officer or mental health professional requesting an emergency evaluation must complete an application for examination of the person in custody and be interviewed by a mental health professional at the evaluating facility.
MC-105 (1/07)(st.3) PEACE OFFICER/MENTAL HEALTH PROFESSIONAL APPLICATION FOR EXAMINATION AS 47.30.705