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';ale of Califormt—Heath and Human Se�neas Apency Department of Mental Hearth APPLICATION FOR 72•HOUR DETENTION DETAINMENT ADVISEMENT FOR EVALUATION AND TREATMENT Confidential ChentlPatient Infprmation My name u See California W 8 I Code Section 5328 1 am a(Peace Officer,etc.)with(Name of Agency).You are not under criminal arrest,but I am taking you for ( w xi'.Sss; exarmnahon by mental heattn professionals at(Name of Facility). W&I Code,Section 5157,requires that each person when first detained for You will be told your ngnts by ere mental hearth staff. psychiatric evaluation be given certain specific information orally,and a record be If taken wto custody at his cw her residerr_e,the person kept of the advisement by the evaluating facility. she!l also be told the/Mowing information to substan- vaNy Me following form: ❑ Advisement Complete ❑ Advisement Incomplete You may bring a few personal,tams with you which I will have to approve.You can make a phone call and/or Goon Cacse for mccmpote Adv:semem leave a note to tell your frieadg and!or family where you have been taken. Adosement Competed By Position Cate To San Joaquin County Mental Health Application is hereby made for the admission of residing at California, for 72-hour treatment and evaluation pursuant to Section 5150, (adulq et seq. or Section 5585 et seq. (minor), of the Welfare and Institutions Code. If a minor, to The best of my knowledge, the legally responsible party appears to belis: (Circle one) Parent; Legal Guardian;Juvenile Court as a WIC 300;Juvenile Court as a WIC 501,602;Conservator. if known, provide names. address and telephone number: The above person condition was called to my attention nde,the•fcilcwing circumstances:(See reverse s`de for definitions) 1 The following information has been established:(Please give sufficiently detailed inlorntation to support the belief that the person for whom evaluation and treatment is sought is in fact a danger to others,a danger to hlmselfi herself and;or gravely disabled.) Based upon the above information it appears that there is probable cause to believe that said person is,as a result of mental disorder: ❑ A danger to himself;herself. ❑ A danger to others. ❑ Gravely disabled adult. ❑ Gravely disabled minor. Sgnat+.a—cord"d;'•+wnow a pace offter.--nt-dt envn>.rq xan ar--,.n burry Date Phone or onus desviir.ty r.+mry N—of La«E'fcrWmert Au—,Y EYatwtan Fed_rty;Person Aow—el Lae_If— .7t Agenoy a EYa.,t �Wdr Ili.— Stockton Police Department Stockton Police Department 22 E.Market Street Stockton,CA 95202 ❑ Weapon was confiscated cord detained person notified of procedure far return of weacan pusuant to W a I Code Secnor.et 92 (officer:unit a prone e) - NOTIFICATIONS TO BE PROVIDED TO LAW ENFORCEMENT AGENCY NOTIFICATION OF PERSON'S RELEASE FROM AN EVALUATION AND TREATMENT FACILITY IS REQUESTED BY THE REFERRING PEACE OFFICER BEACUSE: 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. Notify(ofbcer,unit 6 phone e) ❑ Weapon.was confiscated pursuant to w a l Code Se,cicn 8102. Natty(defter;and a phorw e) SEE REVERSE SIDE FOR INSTRUCTIONS uruirc nueo� r VC,I M11r/,ICA,TAI uenr ru nomee aeev,ne n,ncn+nn , nr.r..n.r'��....,....._.._.. D-11 Page 4 of 5