Free Certification by Peace Officer, Physician, or Qualified Persons - Maryland

CERTIFICATION BY PEACE OFFICER
I am a sheriff, deputy sheriff, State police officer, county police officer, municipal or other local

police officer, or

Secret Service agent who is a sworn special agent of the United States Secret Service or

Department of Homeland Security authorized to exercise powers delegated under 18 U.S.C. § 3056. As to observed the evaluee or evaluee's behavior and, based on the (evaluee), I have personally observation or other information, have

reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or others. Pursuant to Maryland Code, Health­General Article § 10-622, I have transported the evaluee to (emergency facility) for evaluation.

Date and Time

Peace Officer

Department

I.D. No.

CERTIFICATIONS BY OTHER PERSON QUALIFIED UNDER HG § 10-622 AND PEACE OFFICER
I am a physician, psychologist, clinical social worker, licensed clinical professional counselor, psychiatric nurse practitioner, a licensed

clinical nurse specialist in psychiatric and mental health nursing, clinical marriage and family therapist, health officer or

designee of a health officer. I have examined (evaluee). Based on the examination or

other information, I have reason to believe that the evaluee has a mental disorder and presents a danger to the life or safety of the evaluee or others and, in accordance with Maryland Code, Health­General Article § 10-622, have completed the attached Petition for Emergency Evaluation and have requested a peace officer to take into custody and transport the evaluee to the nearest emergency facility for evaluation by a physician. The peace officer explained to me the serious nature, meaning, and content of the petition and I asked the officer to proceed.

Date and Time

Physician or other Qualified Person under HG § 10-622

License No.

I have explained to the Petitioner the serious nature of the petition and the meaning and content of the petition.
Date Peace Officer

Department

I.D. No.

CC-DC 14 (Rev. 11/2008)