Free Presenting information at the probable cause hearing form for facility representatives - California

THE FOLLOWING FORM CAN BE USED BY THE FACILITY REPRESENTATIVE WHEN PRESENTING INFORMATION AT THE PROBABLE CAUSE HEARING
Patient's Name: ___________________________ Admission Date: ______________________ Date of 5150________Written by: Police Mobile Eval Team E.R. Facility Other____________ Criteria: Danger to Self (DTS) Danger to Others (DTO) Gravely Disabled (GD) Summary of Facts: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Treating Physician: ________________________________ Behavior during 72 HRS: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CONSERVATORSHIP? VOLUNTARY? Conservator's name: _________________ Power 7__________ Date it Expires Willing: Yes No Able: Yes No 5270__________ Danger to Others (DTO) Gravely Disabled (GD)

Date: 5250____________ Criteria:

Danger to Self (DTS)

Diagnosis:_____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ MEDICATION DOSAGE FREQUENCY DURATION ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ BEHAVIORS (Give details and connect them to the mental illness): PLEASE NOTE: Dangerous behavior is NOT limited to the patient's behavior during hospitalization. Behaviors prior to current hospitalization or previous hospitalization(s) maybe important for the hearing officer to consider. Every effort should be made to present information with sensitivity and kindness. There is no need to repeat similar facts over and over. Positive

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behavior and areas of improvement since admission should also be mentioned. This will not "lose" the "case" and will help the patient's self-esteem. DTS (NOT just suicidal attempt e.g. leaving gas on, walking in traffic etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ OVER DOSE WEAPONS IDEATION ATTEMPTED PLACING SELF IN DANGEROUS SITUATIONS DTO (NOT just direct threat or assaultive behavior e.g. leaving gas on where others reside setting fires etc.) ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SECLUSION/RESTRAINTS DATES: REASON(S): SELF DESTRUCTIVE ASSAULTIVE AGITATED/OUT OF CONTROL DESTRUCTIVE OF PROPERTY RESTRAINING ORDER TARASOFF GD: FOOD _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SLEEPING ___________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ADLS _______________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ CLOTHING __________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ SHELTER ____________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________

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Prior to hospitalization patient lived: Independent with family/friend Homeless Other___________________________

Board & Care SNF

If this person were released today they would live: Independent with family/friend Care SNF Homeless Other___________________________ INCOME: SOURCE___________________ AMOUNT______________________ LAST HOSPITALIZED: ____________REASON(S): ___________________________________________ DATE

Board &

NUMBER OF PREVIOUS HOSPITALIZATIONS: ____________________________

NOTE IT MIGHT ALSO BE HELPFUL TO SEE SECTION 4 OF THIS HANDBOOK "BEHAVIORAL VARIABLES TO CONSIDER"

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