California uses this two-page application to detain an adult under Welfare and Institutions Code section 5150, or a minor under section 5585, for up to 72 hours of assessment, evaluation and crisis intervention at a county-designated facility. The person initiating the hold records the required advisement, the facts behind probable cause and the legal grounds, then signs. The form travels with the person to the facility.
A peace officer, the professional person in charge of a county-designated facility, a member of its attending staff, a designated member of a mobile crisis team, or another professional person designated by the county completes and signs the whole form. The person being detained completes no part of it.
W&I Code 5150(g)(1) requires the person taking someone into custody to tell them, orally and in an accessible language or modality, who they are, that this is not a criminal arrest, and where the person is being taken for examination. If taken from home, the person is also told they may bring a few approved items, get help turning off appliances or water, and make a call or leave a note. Mark complete or incomplete advisement, the date, who gave it, the language or modality used, and good cause if incomplete.
Name the 5150-designated facility, then the person's name, date of birth and residence. The application requests assessment, evaluation and crisis intervention, or placement for evaluation and treatment, under section 5150 for an adult or section 5585 for a minor. Enter the detainment start date and time; the 72-hour period begins when the person is first detained.
If authorization for voluntary treatment isn't available for a minor or conservatee, name, to the best of your knowledge, the person with legal authority to make medical decisions, with contact information if available, and check parent, legal guardian, conservator or other. For a minor, indicate whether they are under juvenile court jurisdiction as a dependent (W&I Code 300) or a ward (W&I Code 601, 602).
Describe how the person's condition came to your attention, then the specific facts that lead you to believe the person is a danger to self or others, or gravely disabled, as a result of a mental health disorder, a severe substance use disorder, or both. The form asks for specific facts, so record what you observed and what was reported to you, and by whom.
State that you considered the historical course of the person's mental health disorder, severe substance use disorder or co-occurring disorders and describe it, or check that it has no reasonable bearing on the determination, or that no information is available and why. Optionally record who provided the history: name, address, phone number and relationship.
Based on the information above, check each ground that applies: danger to self or danger to others as a result of a mental health disorder; gravely disabled adult due to a mental health disorder, a severe substance use disorder, or co-occurring disorders as defined in W&I Code 5008(h); or gravely disabled minor due to a mental health disorder under W&I Code 5585.25. The boxes checked should match the facts written above.
Name the behavioral health director or designee and the peace officer or designee to be notified of the person's release or end of detention. The referring peace officer checks a box when release notification is requested because the facts would support a criminal complaint, or because a weapon was confiscated under W&I Code 8102.
Sign with your title and, for peace officers, badge number. Enter the name of the law enforcement agency or evaluation facility or person, its address, your name, title and phone, and the date and time of signing. Repeat the detained person's name and date of birth at the bottom of page 2 so both pages stay matched.
Download the current version from the source each time; forms change without notice.
Application for up to 72-Hour Assessment, Evaluation, and Crisis Intervention or Placement for Evaluation and Treatment
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.
Sources for this guide
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The signature block lists a peace officer, the professional person in charge of a facility designated by the county for evaluation and treatment, a member of its attending staff, designated members of a mobile crisis team, or a professional person designated by the county. Clinicians need county designation to initiate the hold; a license alone doesn't authorize it.
Yes. DHCS publishes a Spanish version of the application, DHCS 1801-SP. The detainment advisement on the form must be given orally in a language or modality accessible to the person, or in writing if they can't understand it orally, and the form asks you to record the language or modality you used.
The form states that the 72-hour period begins at the time the person is first detained, not when they reach the facility. Record the detainment start date and time on page 1 of the application so the facility can track the hold from that point.
Yes. Both pages of the DHCS 1801 state that a copy of the application shall be treated as the original. That lets a copy accompany the person to the designated facility, or move between the initiating site and the facility, with the same standing as the signed original.