Before certain residents of Florida nursing homes, assisted living facilities, adult day care centers or adult family-care homes can be admitted voluntarily to a Baker Act receiving facility, an assessor must certify whether they can give express and informed consent. It covers people 60 or older with dementia, people 60 or older facing emergency nursing home transfer, and people whose medical decisions are made by a health care surrogate or proxy.
Page 1 is completed by an assessor, typically from a mobile crisis response service, mental health overlay program or public community mental health center. If mobile crisis cannot respond within 2 hours, an independent licensed professional completes page 2.
Download the current version from the source each time; forms change without notice.
Certification of Ability to Provide Express and Informed Consent for Voluntary Admission and Treatment of Selected Persons from Facilities Licensed Under Chapter 400, F.S.
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Normally an assessor from a mobile crisis response service or other public program. If mobile crisis cannot respond within two hours, the requesting facility may use an independent physician, clinical psychologist, clinical social worker, mental health counselor or psychiatric nurse with no ties to either facility.
Residents seeking voluntary admission from facilities licensed under Chapter 400 who are 60 or older with dementia, 60 or older facing emergency nursing home transfer under s. 400.0255(12), or whose medical decisions are being made by a health care surrogate or proxy under Chapter 765.
The original goes to the receiving facility and is kept in the individual's clinical record. Copies go to the facility where the person was assessed and to the assessor who completed the certification.