Florida's Baker Act lets certain licensed professionals start an involuntary examination by certificate, alongside the court's ex parte order (CF-MH 3001) and the law enforcement report (CF-MH 3052a). On this mandatory two-page DCF form, the professional attests to a personal exam within the preceding 48 hours, ties a mental illness diagnosis to the statutory criteria and documents supporting behavior. The certificate then travels with the person to a receiving facility.
A licensed psychiatrist, physician, clinical psychologist, psychiatric nurse, clinical social worker, mental health counselor, marriage and family therapist, physician assistant, or APRN under s. 464.0123, F.S., completes and signs every section. The form states all sections must be completed and legible.
Print the person's name and the time, date and county of your personal examination, which must be within the preceding 48 hours. Enter your professional license number and check one license type: psychiatrist, physician, clinical psychologist, psychiatric nurse, clinical social worker, mental health counselor, marriage and family therapist, physician assistant, or APRN under s. 464.0123, F.S. The header states all sections must be completed and legible.
Criterion 1 requires reason to believe the person has a mental illness as defined in s. 394.455, F.S.; list all applicable diagnoses with DSM or ICD codes. Then, because of the mental illness, check that the person refused voluntary examination after explanation or cannot determine whether examination is necessary, and check 2a (likely neglect posing a real and present threat of substantial harm) and/or 2b (substantial likelihood of serious bodily harm to self or others in the near future).
Document observations supporting the Section I criteria, including evidence of recent behavior. The form asks for the person's behaviors and statements, specifically any suicidal ideation, previous suicide attempts, homicidal ideation or self-injury. If school personnel are involved, describe the nature of their involvement. Each criterion you checked in Section I should be traceable to something recorded here.
Record other information and the sources you relied on to reach your conclusion. If information came from other people, describe those sources, such as reports of family, friends, other mental health professionals or law enforcement officers, as well as medical or mental health records. This keeps what you personally observed separate from what others reported.
Complete this only if you are a physician as defined in s. 394.455(33), F.S. and, in your clinical judgment, the person has failed or refused to comply with an involuntary outpatient services order. Document the efforts made to solicit compliance with the outpatient services treatment plan. For this section only, a personal examination within the preceding 48 hours is not required.
If law enforcement requests it, give identifying details, if known, to help find the person: age, sex, race or ethnicity, and other details such as height, weight, hair color, clothing and where last seen. Where relevant, note access to a weapon, recent violence or pending criminal charges. The form must be transported with the person to the receiving facility.
Sign, enter the date and time signed with am or pm, and print your name and phone number including area code. The examination time recorded on page 1 must fall within the 48 hours before this signature, so check that the two entries line up before the form leaves your hands.
Download the current version from the source each time; forms change without notice.
Certificate of Professional Initiating Involuntary Examination
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The form lists licensed psychiatrists, physicians, clinical psychologists, psychiatric nurses, clinical social workers, mental health counselors, marriage and family therapists, physician assistants, and advanced practice registered nurses under s. 464.0123, F.S. You check your license type and enter your license number. Law enforcement officers use a different form, CF-MH 3052a.
You must have personally examined the person within the preceding 48 hours, and the form asks for the time, date and county of that exam. The exception is Section IV: a physician initiating examination because the person did not comply with an involuntary outpatient services order does not need a personal exam within 48 hours.
Yes. Section I asks you to list all applicable mental health diagnoses with DSM or ICD codes and to show reason to believe the person has a mental illness as Florida law defines it. Conditions the definition excludes, such as developmental disability or intoxication, do not meet that criterion on their own.
It must travel with the person to the receiving facility, where it is kept in the clinical record. You and the transporting law enforcement agency may keep copies. If law enforcement asks, Section V gives identifying details to help them find the person so the person can be taken into custody for examination.