State forms clinicians sign to start an emergency psychiatric hold, support a petition for court-ordered treatment, or assess capacity for a guardianship.
Each state runs its own process for emergency psychiatric holds, court-ordered treatment and guardianship, with its own clinician forms. This page lists 78 of them, grouped by state. Emergency hold forms come up most: California's DHCS 1801 (the 5150 application), Florida's CF-MH 3052b to start a Baker Act examination, the Massachusetts AA-5 (Section 12) and Kentucky's AOC-712 for a 72-hour hospitalization. For guardianship, Maryland's CC-GN-019 and the Texas Physician's Certificate of Medical Examination give the court a capacity assessment.
Timing and signing rules vary. The CF-MH 3052b exam must fall within 48 hours of signing, New York's OMH 471 certificates must be dated within 10 days before admission, and the Texas guardianship exam must be within 120 days of filing. Kentucky's AOC-712 is sworn before a notary or clerk, Tennessee's MH-5032 is notarized, and Maryland's CC-GN-019 is signed under penalties of perjury. Many states accept psychologists, APRNs or social workers as examiners. Vero Documents fills PDF forms from the visit note and the chart; the clinician reviews and signs.
The '5150' application: documents probable cause that a person is a danger to self, danger to others or gravely disabled due to a mental health or severe substance use disorder, starting an involuntary hold of up to 72 hours.
Certifies a person for 14 days of intensive treatment (or an additional 30 days for grave disability) after a 72-hour hold, triggering a certification review hearing.
Records a clinician's sworn capacity assessment of a proposed conservatee (mental functioning deficits and capacity to consent to medical treatment, placement, dementia medications, etc.) for a probate conservatorship hearing.
JV-220(A)Prescribing physician's statement supporting an application for a juvenile court order to administer psychotropic medication to a dependent or ward in foster care (diagnoses, medications, doses, side effects, alternatives tried).
Short renewal version of JV-220(A) asking the juvenile court to continue the same psychotropic medication at the same maximum dose for a child in foster care.
A licensed behavioral health professional's sworn statement that they examined (or tried to examine) the respondent within 60 days and that the respondent meets, or likely meets, the diagnostic criteria for CARE Act proceedings.
Certifies an additional 14 days of intensive treatment for a person who presents an imminent threat of suicide, supported by affidavits.
Attachment to GC-335 documenting the proposed conservatee's ability to perform everyday activities, used where major neurocognitive disorder (dementia) powers are sought.
Places a person on an emergency mental health hold (up to 72 hours) under C.R.S. 27-65-106 when they appear to be a danger to self or others or gravely disabled due to a mental health disorder.
Documents the comprehensive evaluation of a person on an emergency or court-ordered hold to decide release, voluntary treatment or certification for short-term treatment.
Certifies a person for up to 3 months of short-term involuntary mental health treatment after evaluation, notifying the court and respondent.
Physician's evaluation of a respondent's condition and capacity in an involuntary conservatorship (or review of an existing conservatorship) of the person or estate.
Psychologist's evaluation supporting conservatorship proceedings for a person with an intellectual disability.
Certifies that a qualified professional personally examined the person within the preceding 48 hours and that they appear to meet Baker Act criteria for involuntary examination, initiating transport to a receiving facility.
Receiving-facility petition to the court for involuntary inpatient services, supported by the opinions of a psychiatrist and a second professional who examined the person.
Physician's or psychiatric nurse's finding on whether a person at a receiving or treatment facility is competent to give express and informed consent to voluntary admission and to treatment.
Examiner's determination that a person held for involuntary examination does not meet criteria for involuntary inpatient or outpatient services and may be released.
Certifies that a qualified professional examined the person and found them substance-use impaired and appropriate for emergency admission under the Marchman Act, with a recommended level of care.
Physician's certification that a resident of a nursing home or assisted living facility (ch. 400/429 F.S.) is competent to consent to voluntary admission and treatment before transfer to a receiving facility.
Documents a non-receiving hospital physician's determination, after examination, that a person brought under a Baker Act initiation does not meet involuntary criteria and may be released.
Facility petition asking the circuit court to adjudicate a patient incompetent to consent to mental health or medical treatment and appoint a guardian advocate, supported by a psychiatric professional's opinion.
Physician's certification that a patient is incompetent to consent to treatment, with notice that a health care surrogate or proxy will make decisions.
Petition for court-ordered involuntary outpatient treatment (Florida's assisted outpatient treatment), supported by a psychiatrist's and a second professional's opinions and a proposed treatment plan.
Initiates involuntary transport and mental health evaluation of a person who presents a substantial risk of imminent harm to self or others because of mental illness.
Substance use disorder counterpart of Form 1013: initiates involuntary transport and evaluation of a person with alcohol or drug dependence who presents a substantial risk of imminent harm.
Petition asserting that a person is subject to emergency involuntary or judicial inpatient admission, filed with the circuit court together with examiners' certificates.
IL462-2006Examiner's certificate that a person is subject to involuntary or judicial inpatient admission (and whether immediate hospitalization is needed), supporting the petition in circuit court.
Rule 12.36—Form 4Court-designated examiner's report on whether a respondent is seriously mentally impaired (Iowa Code §229.10) after an application for involuntary hospitalization.
Rule 12.36—Form 8Hospital chief medical officer's report after psychiatric evaluation of a committed respondent, with diagnosis and recommended placement/treatment (Iowa Code §229.14).
Rule 12.36—Form 9Periodic report to the court on the condition and continued need for inpatient treatment of a committed respondent (Iowa Code §229.15(1)).
Rule 12.36—Form 10Periodic report on a respondent under court-ordered outpatient treatment (Iowa's assisted outpatient commitment), stating compliance and continued need (Iowa Code §229.15(2)).
Sworn certification by a qualified mental health professional that a person meets criteria for emergency 72-hour involuntary hospitalization under KRS 202A.
Qualified mental health professional's examination certificate supporting a 60-day or 360-day involuntary hospitalization petition (KRS 202A).
AOC-703AQualified health professional's certification supporting a Casey's Law petition for 60/360-day involuntary substance use disorder treatment (KRS 222.430-.437).
Examiner's certificate in KRS 202C involuntary commitment proceedings (persons with intellectual disability found incompetent to stand trial and dangerous).
Examination certificate supporting involuntary admission of a person with an intellectual disability to an ICF/IID under KRS 202B.
Qualified mental health professional's evaluation certifying whether a respondent meets criteria for court-ordered assisted outpatient treatment (Tim's Law, KRS 202A.0815).
Emergency application, certifying examination and judicial endorsement for involuntary admission of a mentally ill person who poses a likelihood of serious harm (34-B M.R.S. §3863).
Second examiner's certificate, within 24 hours of a Blue Paper admission, that the patient is mentally ill and poses a likelihood of serious harm so the hold may continue (34-B M.R.S. §3863(7)).
Clinician's capacity assessment certificate (Md. Rule 10-202) used to decide whether an individual needs a guardian of the person and/or property and to identify less restrictive alternatives.
Section 12(a) application by a clinician who examined the person and believes hospitalization is needed to avoid likelihood of serious harm, and Section 12(b) authorization by the admitting designated clinician (3-day hold).
Clinician's certificate of a person's clinically diagnosed condition, functional limitations and incapacity, used by the court to decide whether to appoint a guardian and/or conservator (and for Rogers antipsychotic authority).
Clinician's certificate that a person under guardianship or conservatorship no longer meets the standard, supporting termination.
MPC 402Report of a clinical team (physician, licensed psychologist and social worker) required to appoint or continue a guardian for a person with an intellectual disability.
Short clinician affidavit confirming a person remains medically stable as described in the most recent Medical Certificate, avoiding a new MPC 400.
Examiner's report and clinical certificate stating whether an individual requires involuntary mental health treatment (hospitalization, assisted outpatient treatment or combined), after the statutory advisement is read.
Court-appointed examiner's report on an alleged incapacitated individual's infirmities, decision-making ability and need for a guardian (MCL 700.5304).
Clinical supplement filed when an individual on an assisted outpatient or combined order appeals a return to the hospital or facility (MCR 5.743a).
Examiners' certification on whether an individual with an intellectual disability meets criteria for judicial admission to a facility, with recommended treatment and alternatives.
Attending physician's statement of diagnosis, prognosis and behavioral evidence supporting a guardianship/conservatorship petition, with an optional opinion that the respondent cannot attend the hearing.
Petition and examining clinician's certificate for involuntary emergency admission (IEA) of a person who is a danger to self or others because of mental illness (RSA 135-C:27-28).
Physician's or psychologist's certification of an alleged incapacitated person's condition and decision-making capacity, filed with a complaint to appoint a guardian (Division of Developmental Disabilities self-help kit).
Medical professional's certification of an incapacitated adult's current condition and capacity for the guardian's periodic Report of Well-Being.
Two-physician (or physician + psychiatric NP) certification packet for involuntary hospital admission under Mental Hygiene Law §9.27, plus a request for police custody/transport.
Documents a hospital staff physician's finding that a person needs immediate involuntary inpatient care because of a mental illness likely to result in serious harm, and a staff psychiatrist's confirmation for retention beyond 48 hours.
Mental Hygiene Law §9.37 admission initiated by a county Director of Community Services or a physician designee, with hospital psychiatrist examinations within 24 and 72 hours.
Report of court-ordered psychiatric/psychological examination of a juvenile respondent's capacity to understand the proceedings and assist in their defense (Family Court Act §322.1).
Documents the examining physician's finding and staff psychiatrist's confirmation for involuntary emergency admission to a Comprehensive Psychiatric Emergency Program (up to 72 hours).
DMH 5-72-19First-level commitment examination finding whether the respondent meets criteria for inpatient, outpatient or substance use involuntary commitment, sent to the clerk of superior court.
DMH 5-72-19-2Second (24-hour facility) examination deciding whether a respondent held on an IVC remains committable, with recommendation to the court.
DMH 5-72-20AEmergency certificate attached to the first examination certifying that the respondent requires immediate hospitalization to prevent harm, with a transport request (emergency procedure without a custody order).
Form 17.1Expert's evaluation of an alleged incompetent's mental and physical condition and capacity (medical treatment, living arrangements, finances) supporting or opposing an adult guardianship.
Form 20.2Certificate supporting probate court civil commitment of a mentally ill person (R.C. 5122.11), recording the examiners' findings and treatment recommendations.
Form 26.1Physician's sworn certificate supporting a petition for court-ordered involuntary treatment for alcohol and other drug abuse (Casey's Law, R.C. 5119.92-.93), with recommended treatment and willing facilities.
The Section 302 application and warrant for involuntary emergency examination, including the physician's examination that decides whether the person is severely mentally disabled and in need of up to 120 hours of emergency treatment.
Petition for court-ordered involuntary inpatient, partial hospitalization, outpatient or assisted outpatient treatment (up to 90 days or continued), with the results of a current examination.
Petition for court-ordered assisted outpatient treatment under MHPA Section 304(c.2), with a clinical examination finding the person meets AOT criteria.
Court-submitted AOT treatment plan listing required services (case management/ACT), medications and provider information for a person under an AOT order.
Combined emergency detention (Part 1) and first and second Certificates of Need (Parts 2-3) for emergency involuntary admission to a hospital or treatment resource.
Examining professional's sworn certificate that a person admitted on emergency status is subject to involuntary admission, required for the probable cause hearing.
Sworn examiner certificate supporting a complaint for judicial (non-emergency) involuntary commitment; two certificates are required.
Medical evidence required to file an adult guardianship application (Estates Code §1101.103): diagnosis, severity, prognosis, mental functioning, capacity for specific decisions and least restrictive placement.
Application to have a person taken for emergency psychiatric examination, stating the facts showing they are a person in need of treatment (18 V.S.A. §7504).
First certification by a licensed physician that a person subject to an emergency examination application is a person in need of treatment, authorizing admission to a designated hospital for emergency examination (18 V.S.A. §7505).
Psychiatrist's second certification, after the person's admission on an emergency exam, that they are a person in need of treatment, continuing the involuntary hold (18 V.S.A. §7508).
Designated crisis responder's petition for emergency initial detention (up to 120 hours) of a person with a behavioral health disorder under RCW 71.05.153 / 71.34.
Petition for 14-day, 90-day or less-restrictive-alternative (outpatient) involuntary treatment under RCW 71.05 for a mental and/or substance use disorder.
Designated crisis responder's petition asking the court for a non-emergency order of initial detention for evaluation and treatment (RCW 71.05.150).
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
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The DHCS 1801, the 5150 application, is completed by a peace officer or a county-designated professional, often a licensed clinician on a mobile crisis team or in an emergency department. Only professionals the county has designated may start a 5150. The form documents probable cause that the person is a danger to self or others, or gravely disabled, because of a mental health or severe substance use disorder. It goes with the person to the LPS-designated facility, and a Spanish version exists.
On form CF-MH 3052b, a psychiatrist, physician, clinical psychologist, psychiatric nurse, LCSW, mental health counselor, marriage and family therapist, PA or APRN certifies that the person appears to meet Baker Act criteria. The examiner must have personally examined the person within the preceding 48 hours, and the form asks for DSM or ICD diagnosis codes and a description of behaviors. It travels with the person to the receiving facility, which sends a copy to the DCF Baker Act Reporting Center.
The Physician's Certificate of Medical Examination, adopted for statewide use in Texas statutory probate courts. It records diagnosis, severity, prognosis, mental functioning, capacity for specific decisions and the least restrictive placement, from an exam within 120 days of filing. It goes back to the applicant's attorney, who files it with the guardianship application in the county probate court. Counties post their own copies, and a 2023 revision titled Health Care Provider's Certificate also lets psychologists and APRNs sign.
It depends on the state. New York's OMH 471 needs certificates from two examining physicians, or a physician and a psychiatric nurse practitioner. Michigan requires two PCM 208 clinical certificates for hospitalization, one by a psychiatrist. Tennessee's judicial commitment takes two MH-5032 certificates, and Illinois needs two IL462-2006 inpatient certificates for continued detention. In Kentucky, two AOC-720A certifications, one by a psychiatrist, are typically required for the final hearing.