Tennessee MH-5034: Certificate for Probable Cause

After a person is admitted on emergency status, the court's probable cause hearing under Tenn. Code Ann. § 33-6-421 relies on two sworn certificates of need. A clinician meets this one when personally examining the admitted person. It documents facts and reasoning for four commitment criteria and certifies that, without continued treatment, the person's condition is likely to deteriorate until they would again be admittable under § 33-6-403.

Who completes it

The examiner checks one box: licensed physician; psychologist with health service provider designation, when a licensed physician completed the other certificate; or qualified advanced practice provider under § 33-6-407(a) who is not in a collaborating agreement with that physician. A notary completes the sworn-to-and-subscribed block.

Submitting and payment

How to submit it
The signed and notarized certificate is filed with the general sessions or probate court that holds the probable cause hearing, together with the second certificate of need.

Good to know

  • Each of four criteria needs its own facts and reasoning: mental illness or serious emotional disturbance, substantial likelihood of serious harm, need for care, training or treatment, and unsuitability of less drastic alternatives.
  • Unlike the judicial certificate, the examiner also certifies that if involuntary treatment stops, the condition is likely to deteriorate until the person would again be admittable under § 33-6-403.
  • If the person is a child and the certificate is executed for continued commitment under § 33-6-421, the examiner also certifies having professional experience with children.
  • It follows an emergency admission on the MH-5542. The hearing can be waived on MH-5108, and a non-emergency judicial commitment uses the MH-5032 instead.

Get the official form

Download the current version from the source each time; forms change without notice.

Certificate of Need Required under Tenn. Code Ann. §33-6-421 for Probable Cause Hearing

How this list is checked

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Frequently asked questions

When is the Tennessee MH-5034 used?

After a person has been admitted on emergency status, when the court holds the probable cause hearing required by Tenn. Code Ann. § 33-6-421. The examining professional certifies that the person meets the criteria for involuntary care and treatment, and the certificate is filed with the general sessions or probate court.

Who can sign the MH-5034?

A licensed physician, a psychologist with health service provider designation, or a qualified advanced practice provider. Since July 1, 2024, that means a nationally certified psychiatric-mental health advanced practice nurse or a physician assistant certified in psychiatry, whose collaborating physician did not sign the other certificate. An HSP psychologist's certificate must be paired with a physician's.

Is the MH-5034 notarized?

Yes. It ends with a sworn-to-and-subscribed block for a notary public, below the examining professional's signature, date, time and phone number. The current fillable edition is MH-5034 (Rev. 6/24), updated for the Title 33 amendments that took effect July 1, 2024.