Fill and Sign the Form Mc 105 Notice of Emergency Detention and Application

Page 1 of 2 MC-105 (10/13)(cs) NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUA TIONAS 47.30.705 NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION (AS 47.30.705) Instructions AS 47.30.705 authorizes custody for emergency evaluation when considerations of safety do not allow initiation of involuntary commitment procedures. Peace Officers: This form must be completed when you take a person into emergency protective custody under AS 47.30.705. Give the completed form to the h\ ealth care professional when you deliver the person to the health care facility. Psychiatrists, Physicians, Psychologists: This form must be completed when a person is brought to a health care facility by someone other than a peace officer, and the person is detained for examination and evaluation.  If this form is completed and a Petition for Order Authorizing Hospitalization for Evaluation (form MC-100) is later filed with the court, this form must be attac hed to the Petition. PERS ON IN CUSTODY Name: First Middle Last Date of Birth: Gender: Race: Married: yes no Respondent is a minor. Parents/guardian contact information is as follows: Name(s): Address: Phone: PROBABL E CAUSE I certify that probable cause exists under AS 47.30.705 to believe that the above-named person is mentally ill and as a result of that condition is: Gravely disabled Likely to cause serious harm to self Likely to cause serious harm to others of such an immediate n ature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700. Information Supporting Probable Cause: Page 2 of 2 MC-105 (10/13)(cs) NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUA TIONAS 47.30.705 LOCATION OF PERSON IN CUSTODY Taken into emergency custody on (date) at (time) am pm. Taken into custody by: Peace Officer Ambulance Other person (name and relationship to patient) Delivered to (facility) on (date) at (time) am pm. PERS ON MAKING THIS APPLICATION I certify that I am a: Peace Officer Psychiatrist licensed to practice in Alaska or employed by the federal government Physician licensed to practice in Alaska or employed by the f ederal government Clinical psychologist licensed by the state Board of Psychologist and Psychological Associate E xaminers Signature of Person Making this Application Print or Type Name Daytime Telephone Number(s) Mailing Address City State Zip AS 47.30.705 provides: Emergency detention for evaluat ion. (a) A peace officer, a psychiatrist or physician who is licensed to practice in this state or employed by the federal government, or a clinical psychologist licensed by the state Board of Psychol ogist and Psychological Associate Examiners who has probable cause to believe that a person is gravel y disabled or is suffering from mental illness and is likely to cause serious harm to self or others of such immediate nature that considerations of safety do not allow initiation of involuntary commitment proc edures set out in AS 47.30.700, may cause the person to be taken into custody and delivered to the nearest evaluation facility. A person taken into custody for emergency evaluation may not be placed in a jail or ot her correctional facility except for protective custody purposes and only while awaiting transporta tion to a treatment facility. However, emergency protective custody under this section may not include pl acement of a minor in a jail or secure facility. The peace officer or mental health professional shall co mplete an application for examination of the person in custody and be interviewed by a mental health professional at the facility.