This Georgia certificate is the addictive diseases counterpart to Form 1013. An examining clinician certifies that a person appears to be alcoholic, drug dependent or a drug abuser and either presents a substantial risk of imminent harm or is incapacitated by substances on a recurring basis, authorizing a peace officer to take them to an emergency receiving facility for examination.
A licensed physician, psychologist, LCSW, LPC, APRN, psychiatric/mental health clinical nurse specialist or LMFT who examined the person signs the certificate. Referring facility staff confirm a bed, and the peace officer or transporter completes page 2.
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 2013)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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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 who personally examined the person within the preceding 48 hours.
The certificate expires 7 days after it is executed. The peace officer should make diligent efforts to take the person into custody as soon as possible and within 72 hours of receiving the certificate.
The date and time of the examination, the observations supporting the opinion that the person appears alcoholic, drug dependent or drug abusing, and whether they have committed or expressed recent violence to others or self, or are incapacitated by substances on a recurring basis, with an example.