Kentucky district courts rely on the AOC-712 when a petitioner seeks a 72-hour involuntary psychiatric hospitalization under KRS 202A. A clinician meets it after examining the respondent at a regional community program, by telehealth, or as the psychiatrist the court ordered to perform the examination. The sworn certification supports the court's 72-hour hospitalization order (AOC-713) and records medications, allergies and interventions already tried.
A qualified mental health professional completes the whole three-page affidavit, checking their credential from the KRS 202A.011 list (physician, psychiatrist, psychologist, qualifying psychiatric nurse, social worker, therapist, counselor or physician assistant). A notary or other official completes the sworn-statement block.
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Certification of Qualified Mental Health Professional for 72 Hour Hospitalization
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A qualified mental health professional as defined in KRS 202A.011, who also states whether they are a staff member of a regional community program, an individual qualified and licensed to examine by telehealth, or the psychiatrist the court ordered to perform the examination. The full credential list is printed on page 1.
Besides the facts showing the respondent is a danger or threat of danger if not hospitalized, the examiner names who the respondent represents a danger to and indicates whether those people have been notified, then explains why hospitalization is the least restrictive alternative available.
Yes, where known. Item 5 asks for the respondent's Social Security number, date of birth, age, race, sex and contact details, whether a legally appointed guardian exists, and the name and relationship of next of kin or another interested party.