Psychiatrist 60 Day IMO Affadavit
Precision Psychiatric Services, Inc
Patient Name:
Date of Birth:
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Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Psychiatrist:
Please Select
Arul Sangani, MD
Gursimran Kehal, DO
Rama Yasaei, MD
Matthew Bryan, DO
Abdolreza Saadabadi, MD
Mandeep Bagga, MD
Date of Most Recent Evaluation:
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2 digit month, 2 digit day, 4 digit year
Date
Does the patient continue to require an Involuntary Medication Order?
Yes, I affirm that the criteria for Involuntary Medications continues to exist and a court order continues to be necessary.
No, an involuntary medication order is no longer necessary. Please vacate the order.
Involuntary Medication Conditions:
I affirm that the patient is suffering from a serious mental illness (SMI)
I affirm that, as a result of that mental disorder, the inmate is gravely disabled and does not have the capacity to refuse treatment with psychiatric medications, or is a danger to self or others.
I have prescribed one or more psychiatric medications for the treatment of the inmate's disorder, I have considered the risks, benefits, and treatment alternatives to involuntary medication, and I have determined that the treatment alternatives to involuntary medication are unlikely to meet the needs of the patient.
The inmate has been advised of the risks and benefits of, and treatment alternatives to, the psychiatric medication and refuses, or is unable to consent to, the administration of the medication.
Facts leading to the determination of above:
Signature
Date:
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2 digit month, 2 digit day, 4 digit year
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Continue
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Should be Empty: