AMPM Policy 320-Q, Exhibit 320-Q1,
Application for Voluntary Evaluation
(PursuanttoA.R.S.§36-522)Theundersignedherebyrequestsamentalhealthevaluationtobeperformedbypsychiatrists,psychologists,andsocial workersat onthefollowingterms:
Regional Authority
Inpatient,Iagreetoremainasaninpatientintheaboveagencyforaperiodofnotmorethan72hours. Iunderstandthat,attheendofthatperiod,theagencymustreleasemeorfileforaPetitionforCourt-OrderedTreatment,inwhichcaseImaybehelduntilthecourtholdsahearing,whichshallbenolongerthansixdaysfromthedateoffilingthepetition,excludingweekendsandholidays. IfsuchaPetitionisfiled,Iwillhavetherighttorepresentationbyalawyer,andthecourtwillappointoneformeifIcannotaffordone.
Outpatient,Iagreetokeepallscheduledappointmentsrequiredforacompleteevaluation,tothebestofmyability. I understandthatifIfailtoappear,aPetitionforCourt-OrderedEvaluationorTreatmentmaybefiled,inwhichcaseImaybedetainedandrequiredtoundergoinvoluntaryevaluationandtreatment. IfsuchaPetitionisfiled,Iwillhavetherighttorepresentationbyalawyer,andthecourtwillappointoneformeifIcannotaffordone.
Iunderstandthatthephysician-patientprivilegedoesnotapply,andinformationIgiveduringthisevaluationmaybeusedincourtinacivilhearingforcourt-orderedtreatment.
IunderstandthatthisevaluationmayleadtoacourthearingtodetermineifIneedfurthertreatmentandthatsuchtreatment,oraninvestigationintotheneedforaguardianship,maybeorderedbyacourt.
IunderstandthatanapplicationformyexaminationhasbeenfiledandIchoosetobeevaluatedvoluntarilyratherthanbycourtorder.
Iunderstandthatmyevaluationmusttakeplacewithinfivedaysofmyapplication.
IunderstandthatIhavearighttorequirethepersonwhohasappliedformyevaluationtopresentevidenceoftheneedforsuchevaluationtoacourtoflawforapprovalordisapprovalandIwaivemyrighttorequirepriorcourtreviewoftheapplication.
IunderstandthatIhavearight,uponwrittenrequest,tobedischargedwithin24hoursofthatrequest(excludingweekendsandholidays)unlessthemedicaldirectoroftheevaluationagencyfilesapetitionforcourt-orderedevaluation.
PresentedBy:
SignatureofApplicant:
PrintedorTypedNameofApplicant:
Date:
Initial Effective Date: 7/01/2016