A clinician who has examined someone in Georgia within the past 48 hours signs this certificate to authorize a peace officer to take the person into custody and transport them to an emergency receiving facility for a mental health evaluation. The certificate expires 7 days after it is signed. Page 2 is the transporter's report, and both pages go with the person and become part of the clinical record.
The examining clinician completes page 1: a licensed physician, psychologist, LCSW, LPC, APRN, psychiatric/mental health clinical nurse specialist or LMFT. Referring-facility staff complete the bed-availability statement when one is used, and the peace officer or other transporter completes the page 2 Report of Transportation.
Enter the date, the Georgia county and the identifying details of the person examined at the top of page 1. The same county and the person's name carry onto the page 2 transport report, so make sure the identification block is legible. Receiving-facility staff use it to match the certificate to the person who arrives and to file it in the right clinical record.
Record the date and time (a.m. or p.m.) you personally examined the person. By signing, you certify the examination took place within the 48 hours before you signed the certificate. A certificate signed after that window does not meet the form's own statement, so sign promptly after the examination and make sure the examination time and signature time on the form are consistent.
State whether the person appears to be mentally ill and either (A) presents a substantial risk of imminent harm to self or others, shown by recent overt acts or recent expressed threats of violence that make physical injury probable, or (B) appears so unable to care for their own physical health and safety that an imminently life-endangering crisis exists. Check the criterion your findings support.
Check that the person appears to be mentally ill and mark the observations that apply: recent overt acts or threats toward others, recent acts or threats of violence to self, or an imminently life-endangering crisis from inability to care for own health and safety. Use the For example space to describe specific behavior, statements and circumstances you observed, since the facility relies on this narrative.
Sign and print your name, mark your license type from the list on the form, and enter the date, time and your telephone number. The printed instructions above the signature direct the peace officer to act within 72 hours and state the certificate expires 7 days after it is executed. Any legal signature, electronic or handwritten, is acceptable.
When the person is referred from a facility, staff at the referring facility record who they spoke with at the receiving facility and the facility name, confirming a bed is available. This authorizes the peace officer or other person to deliver the individual there for examination. Staff sign with printed name, date and time.
Receiving-facility staff enter their title, signature and the date to confirm a copy of Form 1013 has been placed in the clinical record. The facility then has 48 hours from arrival to discharge the person or execute a Form 1014 or 2014 certificate, followed by transfer to an evaluating facility.
The transporter completes page 2: pickup time, date and location, behavior observed, checkboxes for threats, orientation, cooperation or combativeness, family or others present and their comments, any physical restraints, the person's physical condition, who provided transport, the legal authority (1013 or probate court order), and the time and date of delivery, with printed name and signature.
Download the current version from the source each time; forms change without notice.
Certificate Authorizing Transport to Emergency Receiving Facility and Report of Transportation (Form 1013)
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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 line lists a licensed physician, licensed psychologist, licensed clinical social worker, licensed professional counselor, advanced practice registered nurse, clinical nurse specialist in psychiatric/mental health, or licensed marriage and family therapist. The signer must have personally examined the person within the 48 hours before signing and must print their name next to the signature.
The certificate expires 7 days after it is executed. Within that window, the peace officer is directed to make diligent efforts to take the person into custody as soon as possible, and within 72 hours of receiving the certificate, then transport them to the emergency receiving facility serving the county where they are found.
Staff place a copy of the 1013 in the clinical record and examine the person to decide whether admission is necessary. Within 48 hours of arrival, the facility must either discharge the person or execute a Form 1014 or 2014 certificate, after which the person is transferred to an evaluating facility.
No. The form states that when private transportation by family, friends or other means is deemed safe, it should be encouraged and authorized. Whoever transports completes the page 2 report, noting pickup time and place, behavior observed, any restraints used and the person's physical condition on arrival.