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Get Inpatient Certificate 2022-2024

Ref. 405 ILCS 5/3-403 5/3-602 5/3-607 5/3-610 5/3-702 5/3-813 5/4-306 5/4-402 5/4-403 5/4-405 5/4-501 5/4-611 5/4-705 Inpatient Certificate Re name I personally informed the above-named individual of the purpose of this examination and that he or she did not have to speak to me and that any statements made might be related in court as to the individual s clinical condition or need for services. Additionally if this examination was for the purpose of determining that the above-named individual is developmentally disabled and dangerous I informed the individual of his or her right to speak with a relative friend or attorney before the examination and of his or her right to have an attorney appointed for him or her if he or she so desired. Signature of Examiner On date a.m. at year p.m. I personally examined the time above-named individual. The examination was conducted at name of location Based on the foregoing examination it is my opinion that he or she is A person with mental illness who because of his or her illness is reasonably expected unless treated on an inpatient basis to engage in conduct placing such person or another in physical harm or in reasonable expectation of being physically harmed so as to guard himself or herself from serious harm without the assistance of family or others unless treated on an inpatient basis of the nature of his or her illness is unable to understand his or her need for treatment and if not treated on an deterioration and is reasonably expected after such deterioration to meet the criteria of either paragraph one or paragraph two above An individual who is developmentally disabled and unless treated on an in-patient basis is reasonably expected to inflict serious physical harm upon himself or herself or others in the near future and/or Is in need of immediate hospitalization for the prevention of such harm. I base my opinion on the following including clinical observations factual information I believe that the individual is subject to check one Involuntary inpatient admission and is not in need of immediate hospitalization Judicial inpatient admission and is not in need of immediate hospitalization Date Signature Title Printed Name IL 462-2006 R-8-13 Inpatient Certificate Printed by Authority of the State of Illinois -0- Copies.

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