A Vermont physician or APRN signs this first certification to state that a person is in need of treatment and should be held for admission to a hospital for an emergency examination under 18 V.S.A. section 7505. A clinician meets it in an emergency department or correctional setting after examining someone named in an Application for Emergency Exam. A psychiatrist's second certification follows at the hospital.
A physician or APRN licensed in Vermont who examined the person completes Sections I and II. Designation by the Commissioner of Mental Health is requested but not required by law.
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Physician's Certificate (1st Cert)
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No. The form states that DMH asks all physicians and APRNs to be designated by the Commissioner of Mental Health, but designation is not required by law, so a licensed physician or APRN may complete the certificate without it. DMH's Physician Emergency Exam Certification page explains how to become designated.
Yes. The form says it may be completed by a licensed physician or an advanced practice registered nurse licensed in Vermont who has carefully examined the person's mental condition. The certificate is signed under the penalties of perjury under 18 V.S.A. section 7612(e)(1).
An optional signature waives the certifier's right to receive a copy of the court's notice of hearing under 18 V.S.A. section 7613. The form notes that, even with the waiver, the certifier may still be called to testify at a hearing about the patient.