An examiner uses this one-page Illinois certificate to state that a person is subject to involuntary or judicial inpatient admission and whether immediate hospitalization is needed. It is attached to the Petition for Involuntary/Judicial Admission (IL462-2005) and filed with the circuit court by the facility. Continued detention requires two certificates, one of them signed by a psychiatrist, so most patients have two of these forms in the chart.
A physician, clinical psychologist, qualified examiner or psychiatrist who personally examined the person completes and signs the whole certificate; a psychiatrist must sign one of the two certificates. The petitioner, often a clinician or facility staff member, completes the separate petition on IL462-2005.
Enter the name of the person examined. The statutory references at the top (405 ILCS 5/3-403, 3-602, 3-607, 3-610, 3-702, 3-813 and the 4-series sections for developmental disability) show this one certificate is used for emergency, court-ordered, continued and developmental disability admissions, so the same form serves the first and second examiner.
Sign under the paragraph confirming you personally told the person the purpose of the examination, that they did not have to speak to you, and that statements might be related in court about their clinical condition or need for services. For developmental disability and dangerousness examinations, you also confirm you told them of the right to speak with a relative, friend or attorney and to have an attorney appointed.
Record the date, year and time (a.m. or p.m.) you personally examined the person, then check whether it was conducted in person at a named location or via interactive communication system (telepsychiatry). These entries show when each certificate's examination occurred, which matters because the second examination must follow within 24 hours, excluding weekends and holidays.
Check each standard your examination supports: mental illness with expected conduct causing physical harm; inability to provide for basic physical needs; refusal of or non-adherence to treatment with expected deterioration; or developmental disability with expected serious physical harm in the near future. Check the last box if the person needs immediate hospitalization to prevent such harm.
Describe the mental status findings, behavior, statements and factual history that support each standard you checked. A diagnosis alone does not show why the person meets the standard, so link specific observations, such as threats, self-care failures or treatment refusal, to the criterion. The court sets the petition for a hearing, and this section is the factual support for your opinion.
Check one of four options: involuntary inpatient admission without or with need for immediate hospitalization, or judicial inpatient admission without or with need for immediate hospitalization. Involuntary admission applies to mental illness, judicial admission to developmental disability. Then date and sign, and enter your title and printed name.
Download the current version from the source each time; forms change without notice.
Inpatient Certificate
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Sources for this guide
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A physician, clinical psychologist, qualified examiner or psychiatrist who personally examined the person. Because continued detention needs two certificates and a psychiatrist must sign one of them, the second certificate is usually completed by a psychiatrist who is a different examiner from the first.
Yes. The certificate lets the examiner record that the examination was conducted in person at a named location or via interactive communication system (telepsychiatry). Record the date, year and time with a.m. or p.m., and give the statutory warning before starting, whichever method is used.
Involuntary admission applies to a person with mental illness who meets one of the three listed mental illness standards. Judicial admission applies to a person with a developmental disability expected to inflict serious physical harm in the near future. The final section asks you to check one, with or without need for immediate hospitalization.
The certificate requires you to tell the person they do not have to speak to you. Base your opinion on what you can observe and on factual information, and record those clinical observations and facts in the section that asks what your opinion is based on.