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Form MC 105 Notice of Emergency Detention and Application

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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 health 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 attached to the Petition.

PERSON IN CUSTODY

Name:

Date of Birth: Gender: Race: Married: yes no

Respondent is a minor. Parents/guardian contact information is as follows:

Name(s):

Address:

Phone:

PROBABLE 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 nature that considerations of safety do not allow initiation of involuntary commitment procedures under AS 47.30.700.

Information Supporting Probable Cause:

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.

PERSON 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 federal government

Clinical psychologist licensed by the state Board of Psychologist and Psychological Associate Examiners

AS 47.30.705 provides: Emergency detention for evaluation. (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 Psychologist and Psychological Associate Examiners who has probable cause to believe that a person is gravely 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 procedures 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 other correctional facility except for protective custody purposes and only while awaiting transportation to a treatment facility. However, emergency protective custody under this section may not include placement of a minor in a jail or secure facility. The peace officer or mental health professional shall complete an application for examination of the person in custody and be interviewed by a mental health professional at the facility.

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MC-105 (10/13)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION

AS 47.30.705

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MC-105 (10/13)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION

AS 47.30.705

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What the Form MC 105 Notice of Emergency Detention and Application Is

Form MC 105 Notice of Emergency Detention and Application is a procedural document used to record and initiate emergency detention for an individual believed to pose an imminent risk to themselves or others due to a mental health crisis. The form typically documents observed behavior, the basis for detention, the location where the person will be held for evaluation, and the identity of the reporting parties. It serves as the formal record for subsequent custody, clinical assessment, and any required judicial review. Agencies and facilities use it to ensure chain-of-custody and compliance with local detention statutes and clinical protocols.

Why this Form Matters

The form creates a clear, auditable record of the facts and authority supporting emergency detention. Accurate completion protects patient rights, supports lawful custody, and documents clinical or public-safety justification required by courts and care providers.

Why this Form Matters

Who Typically Completes or Receives Form MC 105

Several professional roles commonly prepare or receive this form depending on the setting and applicable law.

  • Law enforcement officers or emergency responders with statutory detention authority to initiate custody and transport for evaluation.
  • Emergency department clinicians and psychiatric evaluators documenting observed behavior and clinical justification for emergency hold.
  • Hospital intake or county mental health staff responsible for receiving the individual and initiating further evaluation or filing with the court.

Primary Signers and Their Roles

Emergency Clinician

Psychiatrists or licensed mental health clinicians complete clinical observations, record the medical justification for detention, and sign where clinical authority is required. Their documentation supports treatment, legal review, and safe transfer to designated facilities.

Law Enforcement Officer

Officers document the observed conduct, the immediate public-safety concerns, and the actions taken to detain and transport the individual. Their signature establishes custody chain and supports any later judicial proceedings.

Essential Data Items to Include

Patient Name: Full legal name
Date of Birth: MM/DD/YYYY
Incident Location: Street, city, state
Observed Behavior: Concise factual description
Detaining Agency: Officer or facility name
Signature Block: Printed name, title, date

Risks and Legal Consequences of Errors

Wrongful Detention: Civil liability possible
Evidence Exclusion: Procedural defects may limit admissibility
Patient Harm: Delayed care or improper placement
Regulatory Penalties: Licensing complaints risk
Criminal Liability: Excessive force allegations
Recordkeeping Violations: HIPAA or state privacy issues

Common Preparation Pitfalls to Avoid

  • Incomplete incident descriptions that focus on opinion rather than observable facts, which weakens legal and clinical defensibility.
  • Incorrect or missing dates and times that create ambiguity about when custody began and complicate statutory deadlines.
  • Using initials or ambiguous signatory designations instead of full printed names and professional titles required by many jurisdictions.
  • Failing to attach or preserve supporting records such as audio/video, officer reports, or medical triage notes that corroborate the detention.

Step-by-step: Completing Form MC 105

Follow this sequence to produce a clear, defensible emergency-detention record.

  • 01
    Describe the incident: Record observable behavior with specific examples.
  • 02
    Enter identifiers: Use full legal name and DOB exactly.
  • 03
    State the legal basis: Cite the statute or policy authorizing detention.
  • 04
    Sign and date: Include printed name and professional title.

Where to File or Send the Completed Form

Routing depends on local law and institutional procedures; use this as a general map of destinations.

  • Receiving Facility: Emergency department or psychiatric center intake staff.
  • County Mental Health: Public health or behavioral health intake units.
  • Judicial Clerk: Court filing if judicial review is required.
  • Record Retention: Send copy to medical records and agency records.

Key Sections Every Professional Version Should Include

A well-prepared Form MC 105 contains discrete sections that together create a complete legal and clinical record.

Identifying Information

Full legal name, date of birth, and identifying details such as aliases or distinguishing features. Accurate identification prevents mismatches and ensures correct patient tracking across clinical and legal systems.

Incident Narrative

Factual, time-stamped account of observed behavior and statements made by the person or witnesses. Tie observations to objective indicators like threats, attempts, or evidence of self-harm to support the need for detention.

Reason for Detention

Clear statement of imminent risk to self or others, referencing specific actions or threats. Explain why less-restrictive alternatives were not appropriate or available at the time.

Detaining Authority

Name, agency, badge or license number, and contact information for the person initiating detention. This information establishes legal custody and a point of contact for follow-up or subpoena.

Medical Observations

Relevant clinical signs, mental-status exam findings, substance use indicators, and any emergency treatment provided. Include timestamps and medication administered, if any.

Signatures and Witnesses

Signature, printed name, professional title, and date of each signer. Note witness names or notary acknowledgment if local rules require additional authentication.

Configuring an Online Completion Workflow

Set up a digital form workflow that matches your institutional chain-of-custody and privacy controls.

Field Configuration
Authentication Email link or SMS code
Required Fields Make identifiers and incident narrative mandatory
Attachments Allow photos, audio, or video links
Audit Trail Enable timestamp and IP capture

Technical and Distribution Considerations

Ensure the platform satisfies privacy requirements such as HIPAA where relevant, supports secure storage, and provides exportable audit trails for courts and regulatory reviews.

  • Integrations: Supports EHR and records systems
  • Authentication: Email, SMS, or multi-factor
  • Formats: PDF and structured data export

Timing Expectations and Typical Deadlines

Timeframes for review and filing vary by state; act promptly to preserve judicial review rights and patient protections.

Immediate Custody:

Detention may continue until clinical evaluation is completed.

Prompt Filing:

Many jurisdictions require filing with a public agency or court as soon as practicable.

Judicial Review Window:

Many states provide judicial review within 48–72 hours; check local statute.

Transfer Timelines:

Transfer to a designated evaluation facility should occur without unnecessary delay.

Record Submission:

Send copies to medical records and supervising agency promptly.

Key Processing Milestones

A sequential milestone view clarifies steps from incident to legal review.

01

Initial Encounter

Observation and immediate safety actions at the scene.

02

On-Scene Documentation

Complete incident narrative and identifier fields.

03

Transport and Intake

Deliver individual to designated facility for evaluation.

04

Judicial or Administrative Review

Court or hearing officer reviews detention legality.

FAQs and Common Troubleshooting for Form MC 105

Answers to frequent questions about who completes the form, necessary attachments, and common procedural problems.


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eSignature Provider Comparison for Completing and Submitting Form MC 105

Key vendor pricing and feature differences relevant to secure completion and e-submission of the form; signNow is listed first for comparison.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial 7-day free trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes (Business Premium+) Depends on tier Depends on tier Yes Depends on tier
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes (BAA available) Yes Yes No No

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