ࡱ> 241 bjbj>> 4pTpTK   8DX (0tttttccc$X  #cccccttcLttc:,t0R0^' 0(1R# *##ccccccc7`ccc(cccc#ccccccccc : Patient: _______________________________________ Date of involuntary admission: ____________ Time of involuntary admission: ____________ (Date and time of involuntary admission are the date and time at which the hospital begins holding the patient based on a blue paper.) In accordance with the provisions of 34-B M.R.S.A. 3863(7), I hereby certify that: I am a duly qualified: _____ physician _____ licensed clinical psychologist 2. I examined the above-named patient, who has been hospitalized at ____________________ pursuant to an application for emergency involuntary hospitalization (a blue paper), within 24 hours after the patients admission. I examined the above-named patient on ____________________ at _________________. Examination Date Examination Time 3. I am not the examiner who certified the patient for emergency involuntary hospitalization prior to his or her admission. 4. In my opinion, the above-named patient is mentally ill, exhibiting the following symptoms: ___________________________________________________________________________ 5. In my opinion, the above-named patients recent actions and behaviors, described below, pose a likelihood of serious harm due to the patients mental illness: ___________________________________________________________________________ Describe threats of or attempts at suicide or serious self-inflicted harm. ___________________________________________________________________________ Describe recent homicidal or violent behavior or recent conduct placing others in reasonable fear of serious physical harm. ___________________________________________________________________________ Describe recent behavior and how it shows inability to avoid risk or protect self from severe physical or mental harm. 6. In my opinion, adequate community resources are unavailable for care and treatment of the patients mental illness. Date:__________________ ____________________________________ Signature ____________________________________ Printed name     Certification of Need For Psychiatric Hospitalization (24-Hour Certificate) DHHS form, September 2015, under authority of 34-B M.R.S.A. 3802(5)  -0P[]b   j    ] n  % ' ? F K Z q 1 6 7 βΫΣhoK% h -hpYhe} h -hoK%hpYh#Y h -hf~h -h:CJaJh kCJaJh@Uh!thf~h}h+5h}h k6>*aJh}h k6aJh:h-nh kh+512  l m  G H gdpY hdhgd} h^h`gd} hgd} & Fh^hgd}gd kgd} 7 KL!KMNPQgd$HgdoK%gd - hgd}^gd}h^hgd}h^hgd} & Fh^hgd}7 KmtKLNOQRTUW˿h$Hh#YCJ h:CJ h#YCJh#Yh}h#Y5aJhLjhLUh-nhoK%hR7>hh}h kCJaJh khe}h}he}CJaJh}he}CJaJ"QSTVWgdoK%$a$gd}$a$gd#Ygd$H 21h:p8g/ =!"#$% b 666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH6666666666666666666666666666666666666666666666666666666666666666662 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~PJ_HmH nH sH tH @`@ 8gNormalCJ_HaJmH sH tH DA D Default Paragraph FontRiR 0 Table Normal4 l4a (k ( 0No List 4@4 $H0Header  H$6o6 $H0 Header CharCJaJ4 @4 $H0Footer  H$6o!6 $H0 Footer CharCJaJ@@2@ e} List Paragraph ^PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭V$ !)O^rC$y@/yH*񄴽)޵߻UDb`}"qۋJחX^)I`nEp)liV[]1M<OP6r=zgbIguSebORD۫qu gZo~ٺlAplxpT0+[}`jzAV2Fi@qv֬5\|ʜ̭NleXdsjcs7f W+Ն7`g ȘJj|h(KD- dXiJ؇(x$( :;˹! I_TS 1?E??ZBΪmU/?~xY'y5g&΋/ɋ>GMGeD3Vq%'#q$8K)fw9:ĵ x}rxwr:\TZaG*y8IjbRc|XŻǿI u3KGnD1NIBs RuK>V.EL+M2#'fi ~V vl{u8zH *:(W☕ ~JTe\O*tHGHY}KNP*ݾ˦TѼ9/#A7qZ$*c?qUnwN%Oi4 =3N)cbJ uV4(Tn 7_?m-ٛ{UBwznʜ"Z xJZp; {/<P;,)''KQk5qpN8KGbe Sd̛\17 pa>SR! 3K4'+rzQ TTIIvt]Kc⫲K#v5+|D~O@%\w_nN[L9KqgVhn R!y+Un;*&/HrT >>\ t=.Tġ S; Z~!P9giCڧ!# B,;X=ۻ,I2UWV9$lk=Aj;{AP79|s*Y;̠[MCۿhf]o{oY=1kyVV5E8Vk+֜\80X4D)!!?*|fv u"xA@T_q64)kڬuV7 t '%;i9s9x,ڎ-45xd8?ǘd/Y|t &LILJ`& -Gt/PK! ѐ'theme/theme/_rels/themeManager.xml.relsM 0wooӺ&݈Э5 6?$Q ,.aic21h:qm@RN;d`o7gK(M&$R(.1r'JЊT8V"AȻHu}|$b{P8g/]QAsم(#L[PK-![Content_Types].xmlPK-!֧6 0_rels/.relsPK-!kytheme/theme/themeManager.xmlPK-!0C)theme/theme/theme1.xmlPK-! ѐ' theme/theme/_rels/themeManager.xml.relsPK]  \\7   Q L# @0(  B S  ?JKMNPQSTVWKMNPQSTVW33[]bbmm  ?FHHJKKNNW[]bbmm  ?FHHJKKMNNPQSTVW~G&o3m_Z^^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.^`o(. ^`hH. pL^p`LhH. @ ^@ `hH. ^`hH. L^`LhH. ^`hH. ^`hH. PL^P`LhH.~G3m_                  >k,oC -}$?3HGGJ@UX#YNcLdde8g&sl-nEze}f~uuZq}JE6JmHX.0:pY\my~UQ:g$HVq!!tL k+Q!NQKM@@UnknownG*Ax Times New Roman5Symbol3. *Cx Arial7.@CalibriA$BCambria Math"1h*Cg*CgQ9<<!24GG3QHP  $P+2!xx Certification of Need diana.meader Young, Mickey  Oh+'0h   $ 0 <HPX`Certification of Needdiana.meader Normal.dotmYoung, Mickey2Microsoft Office Word@F#@Nl@@<՜.+,0  hp  (fb88 Office of the Attorney GeneralG Certification of Need Title  "#$%&'(*+,-./03Root Entry F̓051Table#WordDocument4SummaryInformation(!DocumentSummaryInformation8)CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q