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';ale of Califormt—Heath and Human Se�neas Apency Department of Mental Hearth <br /> APPLICATION FOR 72-HOUR DETENTION DETAINMENT ADVISEMENT <br /> FOR EVALUATION AND TREATMENT <br /> Confidential ChentlPatient Infprmation My name u <br /> See California W 8 I Code Section 5328 1 am a(Peace Officer,etc.)with(Name of Agency).You <br /> are not under criminal arrest,but I am taking you for <br /> ( w xi'.Sss; exarmnahon by mental heattn professionals at(Name <br /> of Facility). <br /> W d I Code,Section 5157,requires that each person when first detained for You will be told your ngnts by ere mental hearth staff. <br /> psychiatric evaluation be given certain specific information orally,and a record be If tapen wto custody at his cw her residerr_e,the person <br /> kept of the advisement by the evaluating facility. she!l also be told the/Mowing information 1n substan- <br /> vaNy Me following form: <br /> ❑ Advisement Complete ❑ Advisement Incomplete You may bring a few personal,tams with you which I <br /> will have to approve.You can make a phone call and f Or <br /> Goon Carse for mccmpote Adv:semem leave a note to tell your friends and!or family where you <br /> have been taken. <br /> Advisement Competed By Position Cate <br /> To San Joaquin County Mental Health <br /> Application is hereby made for the admission of <br /> residing at California, for <br /> 72-hour treatment and evaluation pursuant to Section 5150, (adulq et seq. or Section 5585 et seq. (minor), of the Welfare and <br /> Institutions Code. If a minor, to The best of my knowledge, the legally responsible party appears to belis: (Circle one) Parent; <br /> Legal Guardian;Juvenile Court as a WIC 300;Juvenile Cour,as a WIC 601,602;Conservator. if known, provide names. address <br /> and telephone number: <br /> The above person's condition was called to my attention nde,the•fcilcwing circumstances:(See reverse s`de for definitions) <br /> 1 <br /> The following information has been established:(Please give sufficiently detailed inlorntation to support the belief that the person for <br /> whom evaluation and treatment is sought is in fact a danger to ot`ers,a danger to hlmselfi herself and;or gravely disabled.) <br /> Based upon the above information it appears that there is probable cause to believe that said person is,as a result of mental disorder: <br /> ❑ A danger to himself;herself. ❑ A danger to others. ❑ Gravely disabled adult. ❑ Gravely disabled minor. <br /> Sgnat+.a—aro ilia'•+wnpn 0 p...off t.r.--nt-dt en.narq xae ar--,.n burry Dat. Peon. <br /> or onus d.sviir.d y r.+mry <br /> N—of La«E�fcrwmert Au—,a EvatwEan Fad:rty:Person Aow—of La._If— .7t Ag.rcy a E4u,­=Wil,Ili.— <br /> Stockton Police Department Stockton Police Department <br /> 22 E.Market Street <br /> Stockton,CA 95202 <br /> ❑ Weapon was confiscated cord detained person notified of procedure far return of weacan pusuant to W a I Code Secnor.et 92 <br /> (officer:unit a prone e) - <br /> NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY <br /> NOTIFICATION OF PERSON'S RELEASE FROM AN EVALUATION AND TREATMENT FACILITY IS REQUESTED BY THE REFERRING PEACE OFFICER BEACUSE: <br /> Person has been relened under orcumstances in which crmmal charges might be fired Pursuant to W a I Code SeVions 5152.1 and 5152.2. <br /> Notify(oftcer•unit 6 phone e) <br /> ❑ Weapon.was confiscated pursuant to w i l Code Se,cicn 8102. <br /> Natty(defter;and a phot.e) <br /> SEE REVERSE SIDE FOR INSTRUCTIONS <br /> D-11 <br /> Page 4 of 5 <br />