5150 Legal Hold Form

5150 Legal Hold Form
Complete Advisement?*

Complete AdvisementIncomplete Advisement
Cause for INCOMPLETE Advisement*
Date of Advisement/Attempt*

MonthDayYear
Date
Evaluator Name:*
Your Name:*
Your position:*
Language or Modality Used:*
Other Language or Modality Used:*
What 5150 facility will the patient be referred to:*
Patient Name:*
Patient Date of Birth:*

MonthDayYear
Date
Patient address (write Homeless + Name of City, if homeless)*
Detainment Start Date*

MonthDayYear
Date
Detainment Start Time*

Hour Minutes

AM/PM Option
Is the patient a minor or have a legal guardian or conservator?*

NoYes
Who has legal authority over the patient?*

Parent(s)Legal Guardian(s)ConservatorOther
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 determinationNo information available because:
Historical information considered:*

0/430
Optional: History Provided by (Name 1)
Address
Relation
Phone Number
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?*

Noyes, there was a crime that possibly occurred and a criminal complaint may be filedYes, a weapon was confiscated pursuant to Section 8102 W&I Code.
Your Name*
Title/Badge Number*
Time*

MonthDayYear
Date
Time*

Hour Minutes

AM/PM Option
Your or Facility Phone #*
Facility Address:*
Facility City
Facility State
Facility Zip
Signature:*

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Name of Law Enforcement Agency or Evaluation Facility/Person*
Name of Individual Detained (for page 2)*
DOB (for page 2)*

MonthDayYear
Date
Mandatory Extra Information County is requiring:
Gender Identity:*

MaleFemaleTransgender Male to FemaleTransgender Female to maleDeclined to stateNon-binary/genderqueeranother gender identity/questioningUnknown/Not reported
Race*

American Indian / Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteMore than one raceUnknown/Not reportedDeclined to stateOther
Ethnicity*

Not Hispanic or LatinoHispanic / LatinoUnknown/Not reportedDeclined to state
Sexual Orientation*

Straight / HeterosexualGay / LesbianBisexualQueerAnother Sexual Orientation / QuestioningUnknown/Not reportedDeclined to state
Sex*

MaleFemaleUnknown/Not reportedDeclined to state
Veteran*

Non VeteranVeteranUnknown/Not reportedDeclined to state
Housing Status*

Stably HousedImminent Risk of HomelessnessLiterally Homeless and ShelteredLiterally Homeless and UnshelteredHomelessness UnspecifiedJail/Correctional FacilityUnknown/Not reportedDeclined to state
Do you need a co-signer?

YesNo
Email of Cosigner
example@example.com

For Cosigner Only:
Name of Cosigner:
Title of Cosigner
Signature

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5150 Legal Hold Form

Mandatory Extra Information County is requiring: