5150 Legal Hold Form
Complete Advisement?
*
Complete Advisement
Incomplete Advisement
Cause for INCOMPLETE Advisement
*
Date of Advisement/Attempt
*
/
Month
/
Day
Year
Date
Evaluator Name:
*
Your Name:
*
Your position:
*
Language or Modality Used:
*
Please Select
English
Spanish
ESL
Other:
Other Language or Modality Used:
*
What 5150 facility will the patient be referred to:
*
Please Select
Kaweah Health (or any LPS facility)
Sierra View Hospital (or any LPS facility)
Adventist Tulare (or any LPS facility)
Other
Patient Name:
*
Patient Date of Birth:
*
/
Month
/
Day
Year
Date
Patient address (write Homeless + Name of City, if homeless)
*
Detainment Start Date
*
/
Month
/
Day
Year
Date
Detainment Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Is the patient a minor or have a legal guardian or conservator?
*
No
Yes
Who has legal authority over the patient?
*
Parent(s)
Legal Guardian(s)
Conservator
Other
Is the minor under the jurisdiction of the juvenile court?
*
W&I Code 601, 602 (ward)
W&I Code 300 (dependent)
The detained person’s condition was called to my attention under the following circumstances:
*
0/430
Specific facts that I have considered that lead me to believe that this person is, as a result of a mental health disorder, a danger to others, a danger to self or gravely disabled:
*
0/430
Historical course of the person's mental disorder that was considered:
*
Relevant information was available as follows:
No reasonable bearing on determination
No information available because:
Historical information considered:
*
0/430
Optional: History Provided by (Name 1)
Address
Relation
Phone Number
Format: (000) 000-0000.
CRITERIA
*
Danger to Self (DTS)
Danger to others (DTO)
Gravely disabled (as defined in W&I Code section 5008 or 5585.25)
Gravely disabled MINOR
Do the authorities need to be notified after the patient is released from the hold?
*
No
yes, there was a crime that possibly occurred and a criminal complaint may be filed
Yes, a weapon was confiscated pursuant to Section 8102 W&I Code.
Your Name
*
Title/Badge Number
*
Time
*
/
Month
/
Day
Year
Date
Time
*
Hour Minutes
AM
PM
AM/PM Option
Your or Facility Phone #
*
Facility Address:
*
Please Select
Adult Pre-Trial Facility, 36650 Rd 112
Bob Wiley Detention Facility, 36712 Rd 112
South County Detention Center, 1960 W Scranton Ave
Facility City
Facility State
Facility Zip
Signature:
*
Name of Law Enforcement Agency or Evaluation Facility/Person
*
Name of Individual Detained (for page 2)
*
DOB (for page 2)
*
/
Month
/
Day
Year
Date
Mandatory Extra Information County is requiring:
Gender Identity:
*
Male
Female
Transgender Male to Female
Transgender Female to male
Declined to state
Non-binary/genderqueer
another gender identity/questioning
Unknown/Not reported
Race
*
American Indian / Alaskan Native
Asian
Black or African American
Native Hawaiian or Pacific Islander
White
More than one race
Unknown/Not reported
Declined to state
Other
Ethnicity
*
Not Hispanic or Latino
Hispanic / Latino
Unknown/Not reported
Declined to state
Sexual Orientation
*
Straight / Heterosexual
Gay / Lesbian
Bisexual
Queer
Another Sexual Orientation / Questioning
Unknown/Not reported
Declined to state
Sex
*
Male
Female
Unknown/Not reported
Declined to state
Veteran
*
Non Veteran
Veteran
Unknown/Not reported
Declined to state
Housing Status
*
Stably Housed
Imminent Risk of Homelessness
Literally Homeless and Sheltered
Literally Homeless and Unsheltered
Homelessness Unspecified
Jail/Correctional Facility
Unknown/Not reported
Declined to state
Do you need a co-signer?
Yes
No
Email of Cosigner
example@example.com
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For Cosigner Only:
Name of Cosigner:
Title of Cosigner
Signature
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Should be Empty: