EMERGENCY DETENTION NOTICE, STATEMENT OF FACTS AND

CERTIFICATE OF LAW ENFORCEMENT OR EXAMINER

PART 1

Step 1Immediately contact the director of a mental health center, an examiner, a licensed physician or mental health professional, who shall conduct a preliminary examination within 24 hours after the detention.

Person Contacted: Date Timeam / pm

Step 2Immediately notify the person responsible for the care and custody of the detained person, if known, at the time and place of detention.

Person Contacted: Date Timeam / pm

Step 3Informed detained person orally and in writing (by giving him a copy of this report) of his rights as provided by W.S. 1977 25-20-209;

  1. You have the right to contact your family;
  2. You have the right to contact an attorney;
  3. You have the right to have an attorney appointed at no cost to you if you cannot afford one;
  4. You have the right to remain silent;
  5. Anything you say may be used as a basis for involuntary hospitalization.

Proposed patient informed of his rights:

Date Signature

Timeam / pm Witness

Step 4Proposed patient detained: Timeam / pm Date

If an examiner finds the proposed patient to be mentally ill, and an application for involuntary hospitalization is filed, a preliminary hearing must be held no later than seventy-two (72) hours after initial detention, excluding Saturdays, Sundays, or holidays. For purposes of W.S. 25-10-101, et. Seq., Saturdays, Sundays, and holidays begin at midnight. Using the above formula, the 72 hour emergency detention period for the proposed patient will expire on:

Date Timeam / pm

PART II

NameDate of BirthAddress

Place of contactPrevious Psychiatric Care

Resident of Wyoming YES NO (If no checked, see below)

Form 3-81 Page 1 of 2 Revised 2/2000

Circle items that apply:

APPEARANCE/GENERAL BEHAVIOR

DRESS: Neat, Untidy, Dirty, Eccentric

POSTURE: Erect, Tense, Relaxed, Lying Down

FACIAL EXPRESSION: Fixed, Changing, Angry, Perplexed, Sad, Happy, Suspicious

PHYSICAL ACTIVITY: Normal, Underactive, Overactive

EMOTIONAL REACTION

ATTITUDE: Composed, Polite, Cooperative, Reserved, Indifferent, Silent, Scared, Sad, Happy, Carefree, Cocky, Excited, Angry, Sarcastic, Antagonistic, Suspicious, Insulting, Profane, Combative, Sleepy

TALK: FORM: Logical, Conversational, Illogical, Rambling, Nonsensical

RATE: Normal, Overtalkative, Undertalkative

QUALITY: Controlled, Humorous, Shouting, Forceful, Screaming

EXPRESSIONS: Ideas of being persecuted; Feels people are watching and/or talking about him; Ideas of grandeur; Strange or bizarre physical complaints; Very self-critical; hearing voices; Seeing things; Homicidal thoughts; Suicidal thoughts; Unusual sexual ideas

DOES PERSON KNOW: Who he is? (Yes/No); Where he is? (Yes/No); Date? (Yes/No); How he/she feels? (Yes/No)

Form 3-81 Page 1 of 2 Revised 2/2000

Pursuant to W.S. 1977 25-10-109 was detained because of recent

Name of person detained

overt acts or omissions which have given the undersigned reasonable cause to believe that said person is mentally ill, and poses an immediate risk of serious physical injury or illness to himself, or of serious physical injury or illness to himself, or of serious physical injury to others.

The circumstances by which the undersigned believes there is probable cause leading to the emergency detention are as follows:

Diagnostic Impressions:

I believe the detainee is a non-resident of the State of Wyoming because

I hereby state that to the best of my knowledge, the above stated information is correct.

Dated this day of ,20, AM / PM

Signature

(Police Officer or Examiner)

Form 3-81 Page 1 of 2 Revised 2/2000