New York Codes, Rules and Regulations › Title 14 - DEPARTMENT OF MENTAL HYGIENE › Appendices › Appendix 1

Current through Register Vol. 46, No. 28, July 10, 2024
ADMISSION FORMS
INDEX
Form 19--D.M.H. Order of Transfer
Form 41--D.M.H. Application for Voluntary or Minor Voluntary
				Admission to a School
Form 42--D.M.H. Notice of Status and Rights--Voluntary or Minor
				Voluntary Admission
Form 42a--D.M.H. Notice of Status and Rights--Conversion to
				Voluntary or Minor Voluntary Status
Form 43--D.M.H. Application for Non-objecting or Involuntary
				Admission to a School
Form 43a--D.M.H. Certificate of Examination by Examining
				Physician or Certified Psychologist
Form 44--D.M.H. Notice of Status and Rights--Involuntary
				Admission
Form 44a--D.M.H. Notice of Status and Rights--Conversion to
				Involuntary Status
Form 44b--D.M.H. Notice of Status and Rights--Non-objecting
				Admission
Form 45--D.M.H. Application for Court Authorization to Retain
				Resident
Form 45a--D.M.H. Notice of Application for Court Authorization
				to Retain Resident
Form 451--D.M.H. Application for Voluntary or Minor Voluntary
				Admission to an Alcoholism Facility
Form 452--D.M.H. Notice of Status and Rights--Voluntary or
				Minor Voluntary Admission (Alcoholism)
Form 452a--D.M.H. Notice of Status and Rights--Conversion to
				Voluntary or Minor Voluntary Status (Alcoholism)
Form 453--D.M.H. Application for Involuntary Admission to an
				Alcoholism Facility
Form 453a--D.M.H. Medical Certificate of Alcoholism
Form 454--D.M.H. Notice of Status and Rights--Involuntary
				Admission (Alcoholism)
Form 454a--D.M.H. Notice of Status and Rights--Conversion to
				Involuntary Status (Alcoholism)
Form 457--D.M.H. Order of Commitment for Psychiatric
				Examination under Family Court Act
Form 459--D.M.H. Identifying Data Sheet
Form 460--D.M.H. Notice of Status and Rights--Voluntary or
				Minor Voluntary Admission
Form 460a--D.M.H. Notice of Status and Rights--Conversion to
				Voluntary or Minor Voluntary Status
Form 461--D.M.H. Notice of Status and Rights--Involuntary
				Admission
Form 461a--D.M.H. Notice of Status and Rights--Conversion to
				Involuntary Status
Form 464--D.M.H. Notice of Hearing
Form 465--D.M.H. Civil Order for Hospitalization
Form 467--D.M.H. Request for Court Hearing
Form 471--D.M.H. Application for Admission of Patient
Form 471a--D.M.H. Certificate of Examining Physician (Mental
				Illness)
Form 471b--D.M.H. Certificate of Examination by Director of
				Community Services or his Designee
Form 471c--D.M.H. Examination for 72 Hour Conversion to Two
				Physician Status
Form 472--D.M.H. Voluntary Request for Hospitalization
Form 474--D.M.H. Record of Emergency Admission
Form 474a--D.M.H. Notice of Status and Rights--Emergency
				Admission
Form 476--D.M.H. Form for the Court Commitment of Certain
				Dangerously Mentally Disabled Patients
Form 476a--D.M.H. Certificate of Examining Physician
Form 476b--D.M.H. Notice of Petition for Order of
				Commitment
FORM 19--D.M.H.
FORM 19 DMH (5/73)
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
ORDER OF TRANSFER
(Pursuant to Section 29.11  of the Mental Hygiene Law)
Albany, N.Y. ____________, 19________,
A written request to this Department having been made for the
				transfer of ____________
____________
a patient at____________,
and the reasons for such transfer being satisfactory, and the
				Mental Health Information Service having been given notice of the proposed
				transfer, it is hereby ordered that the director of said facility discharge
				said patient for transfer to
____________,
and that the director of the latter facility receive said
				patient for treatment upon the presentation of this original order, together
				with the original admission paper and case record.
BY THE COMMISSIONER:
______________
(SIGNATURE)
______________
(PRINT NAME)
______________
(TITLE)
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
FORM 45 DMH (1/73) PAGE 2
CERTIFICATION OF SERVICE OF NOTICE
I am the Director of ________, a school for the mentally
				retarded, and hereby certify that, pursuant to Article 33 of the Mental Hygiene
				Law, and in accordance with the Rules and Regulations of the Commissioner of
				Mental Hygiene, I have caused copies of the attached "Notice of Application for
				Court Authorization to Retain Resident" to be served personally, on ________,
				19 ________, on the resident identified in the Application; and to be served by
				mail, posted on ________,19 ________, on the Mental Health Information Service
				and all of the persons whose names appear at the foot of said notice, the
				foregoing being all of those entitled to receive such notice under law. At
				least five days, excluding Sundays and holidays, have elapsed from the time of
				the last service thus made and
(Strike Inapplicable Section Below)
NO HEARING REQUESTED
No request by or on behalf of said resident for a hearing on
				the foregoing application has been received by the undersigned.
HEARING REQUESTED
A request for a hearing has been made by or on behalf of the
				above named resident (copy attached). A record of said resident as required by
				law is attached hereto.
DATE: ________, 19________
______________
SIGNATURE
______________
(PRINT NAME TO BE SIGNED)
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
Image
FORM 476--D.M.H.
FORM 476 DMH (1/73) PAGE 1
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORM FOR THE COURT COMMITMENT OF
CERTAIN DANGEROUSLY MENTALLY DISABLED PATIENTS
SECTION 1
ORDER OF COMMISSIONER OF MENTAL HYGIENE
To Dr.____________, Director of
___________
___________
(ADDRESS)
Information having been presented to me showing that
an involuntary patient at
mentally disabled that his presence in a Department of Mental
				Hygiene facility is dangerous to the safety of other patients therein, the
				officers or employees thereof, or to the community, and full consideration
				having been given thereto, you are hereby directed to make application to the
				Supreme Court or County Court within the County wherein your facility is
				located, or to the Supreme Court in the Judicial District wherein such county
				is located, for an order directing the examination of the said patient pursuant
				to Section 29.13  of the Mental Hygiene Law.
____________
________COMMISSIONER AND DULY AUTHORIZED DESIGNEE OF THE
				COMMISSIONER OF MENTAL HYGIENE
I
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORMS FOR THE COURT COMMITMENT OF CERTAIN DANGEROUSLY MENTALLY
				DISABLED PATIENTS PRESCRIBED BY THE DEPARTMENT OF MENTAL HYGIENE,
PURSUANT TO THE PROVISIONS OF SECTION 29.13  OF THE MENTAL HYGIENE LAW.
INSTRUCTIONS
This booklet contains the forms which are to be used in
				proceedings under Section 29.13  of the Mental Hygiene Law. This
				section of the law provides for court commitment to institutions in the
				Department of Correctional Services of mentally disabled persons who are
				involuntary patients at facilities in the Department of Mental Hygiene and who
				have become so dangerously mentally disabled that their presence in Mental
				Hygiene facilities is dangerous to the Safety of other patients, the officers
				or employees thereof or to the community.
LIST OF FORMS
The following are the forms contained in this booklet:
Form 476 DMH:
Section 1. Order of Commissioner of Mental Hygiene (printed
				separately for completion in Albany only).
Section 2. Notice of Application for Order of
				Examination
Section 3. Application for Order of Examination
Section 4. Affidavit of Service of Notice (of Application for
				Order of Examination)
Section 5. Order of Examination
Form 476A DMH: Certificate of Examining Physician (2
				copies)
Form 476B DMH:
Section 1. Notice of Petition for Order of Commitment
Section 2. Petition
Section 3. Affidavit of Service (of Notice of Petition and the
				Petition)
Section 4. Order of Hearing
Section 5. Affidavit of Service of Order of Hearing
Section 6. Decision of Court After Hearing
Section 7. Court Order of Commitment or Denial
PROCEDURE
1. The Director of the Mental Hygiene facility first obtained
				the Order of the Commissioner of Mental Hygiene or his duly authorized
				designee. This Order can be given verbally over the phone, but must then be
				followed up by a written Order of the Commissioner of Mental Hygiene which
				becomes Section 1 of form 476 DMH. See page 1A of Form 476 DMH for more
				detailed instructions.
2. The Director prepares the "Notice of Application for Order
				of Examination" (Section 2) and the "Application for Order of Examination"
				(Section 3) on Form 476 DMH.
3. Exact photocopies of Section 2 and Section 3 are prepared.
				One copy of each Section is served personally on the patient. Another copy of
				each Section is served either personally or by registered mail upon the Mental
				Health Information Service. The person effecting the service of this notice
				then completes the "Affidavit of Service of Notice (of Application for Order of
				Examination) " (Section 4).
4. The Director attaches the written Order of the Commissioner
				of Mental Hygiene (Form 476 DMH, Page 1) on top of page 1A of Form 476 DMH. He
				then submits the complete application, together with two blank copies of Form
				476A DMH, "Certificate of Examining Physician," to the appropriate court or
				judge. The judge, upon due consideration signs the "Order of Examination"
				(Section 5) designating two examining physicians. These examining physicians
				cannot be connected with the facility where the patient is confined.
II
5. The Court sends copies of the "Order of Examination"
				(Section 5, Form 476 DMH) plus a blank Form 476A DMH to each of the designated
				examining physicians. The examining physicians conduct their examinations of
				the patient and each prepares a "Certificate of Examining Physician" (Form 476A
				DMH) . The completed certificates are then delivered to the Director of the
				Mental Hygiene Facility for presentation to the Court along with his
				Petition.
6. The Director prepares the "Notice of Petition for Order of
				Commitment" (Section 1) and the "Petition" (Section 2) on Form 476B DMH.
7. Exact photocopies of Section 1 and Section 2 of Form 476B
				DMH are prepared. One copy of each Section is served personally on the patient.
				Other copies of both Sections are served either personally or by registered
				mail upon the Mental Health Information Service and upon either the wife,
				husband, father or mother or other nearest relative, if there be any in the
				State, and if there be any such relative, then upon any known friend of the
				patient. Service of this notice must be made at least five days prior to the
				date on which the Petition is to be presented to the court when service is made
				personally. If Service is by mail, three days must be added, making a total of
				8 days required so the minimum period of notice. The person effecting the
				service of this notice then completes the "Affidavit of Service (of Notice of
				Petition and The Petition) " (Section 3).
8. After the expiration of the minimum period of notice as
				indicated above the Director submits the Petition and the Certificates of
				Examination to the court which ordered the examination. Since a hearing is now
				mandated by Law, the judge will prepare the "Order of Hearing" (Section 4), setting a date for the hearing not more than five days from the date of which
				the Petition is received by the court. At this time the judge will also appoint
				counsel to represent the patient at the hearing, if the patient has not
				previously obtained counsel on his own behalf.
9. Copies of the "Order of Hearing" (Section 4) must be
				prepared by the court and served on the parties who are designated in the Order
				as having to he served. A copy of this Order must he served personally on the
				patient and either personally or by registered mail on the Mental Health
				Information Service and the other designated persons. The person effecting
				service of the Order then completes the "Affidavit of Service of Order of
				Hearing" (Section 5).
10. After the hearing is held, the judge completes the
				"Decision of Court After Hearing" (Section 6) and the "Court Order of
				Commissioner or Denial" (Section 7).
11. If an immediate commitment to an institution in the
				Department of Correctional Services is needed pending outcome of this
				proceeding, application must be made to the judge on Form 476C DMH. This form
				(not included in this booklet) contains the petition of the Director and the
				affidavit of two examining physicians that the Director is not able to properly
				care for the allegedly dangerous patient at the facility where he is confined
				and that the patient is in need of immediate treatment. The examining
				Physicians for this purpose may be connected with the Mental Hygiene facility
				where the patient is confined. The form also contains the "Order of Forthwith
				Commitment."
III
PROVISIONS OF THE MENTAL HYGIENE LAW
Section 29.13 -- Proceedings for commitment of certain
				dangerous patients to institutions in the Department of Correction.
(a) As used in this section:
"patient" means a person admitted to a hospital or school in
				the department and retained therein on an involuntary basis pursuant to the
				provisions of this chapter.
"dangerous" means that a patient has committed or is liable to
				commit an act or acts which, if committed by a person criminally responsible
				for his conduct, would constitute homicide or felonious assault or is so
				dangerously mentally disabled that his presence in the department hospital or
				school is dangerous to the safety of other patients therein, to the officers or
				employees thereof, or to the community.
(b) The director of any hospital or school in the department
				may, upon order of the commissioner and after notice to the patient and the
				mental health information service, make application to the supreme court or
				county court within the county wherein such facility is located or to the
				supreme court in the judicial district wherein such county is located for an
				order of examination of an allegedly dangerous patient at such hospital or
				school. Such examination shall be conducted by two examining physicians, other
				than a physician connected with such hospital or school, to be designated by
				the court. Each physician, if satisfied, after a personal examination, that
				such patient is dangerous shall make a certificate to that effect.
(c) Upon such certificate of the examining physicians being so
				made, it shall be delivered to the director of the facility, who shall
				forthwith apply by petition to the court which ordered the examination,
				annexing such certificate to his petition, for an order committing such
				allegedly dangerous patient to an appropriate institution in the state
				department of correction. Written notice of such application, together with a
				copy of the petition, shall be served upon the allegedly dangerous patient
				personally, upon the mental health information service, and upon either the
				wife husband, father, mother, or nearest relative of such patient or, if there
				be no such relative within the state, upon any known friend of the patient.
				Such service shall be made at least five days in advance of the return date if
				service is effected personally or at least eight days in advance of the return
				date if service is effected by mail. If there be no such known relative or
				friend within the state, the giving of such notice shall be dispensed with, but
				in such care the petition and the order of commitment shall recite the reasons
				why service of such notice on a relative or friend of the allegedly dangerous
				patient was dispensed with.
(d) The court to which such application for the commitment of
				the allegedly dangerous patient has been made shall order a hearing. The date
				of such hearing shall be fixed at a time not more than five days from the date
				on which the application is received by the court. Such allegedly dangerous
				patient shall be represented by counsel in any such proceedings. The court
				shall hear the testimony introduced by the parties and shall examine such
				allegedly dangerous patient, if deemed advisable in or out of court, and render
				a decision in writing as to such patient's dangerousness. If it be determined
				that such patient is dangerous, the court shall forthwith issue its order
				committing such patient to an appropriate institution in the state department
				of correction for a period not to exceed six months from the date of such
				order. The director of the department facility shall thereupon cause such
				dangerous patient to be delivered to such institution in the department of
				correction and such dangerous patient shall be received into such institution
				and retained there until the expiration of the period of authorized retention
				provided for in the order of commitment or in any further order issued pursuant
				to this section. If such patient is no longer dangerous to safety, he shall be
				released prior to the expiration of any such period in the manner provided in
				sectionsection four hundred nine of the correction law or, if he is in need of
				continued care and treatment, he may be transferred to an in-patient hospital
				or school in the department of mental hygiene upon the order of the
				commissioner of mental hygiene. If the director of the facility
IV
in the department of mental hygiene shall deem that the
				condition of a patient so transferred is in need of continued retention, he
				shall apply to the supreme court or county court prior to the expiration of
				sixty days from the date of such transfer for an order authorizing continued
				retention in accordance with the provisions of this chapter relating to
				application for court authorization for retention of such a mentally ill or
				mentally retarded patient.
(e) If the director or person in charge of the institution in
				the correction department to which the dangerous patient has been committed
				pursuant to this section shall deem that the condition of such patient requires
				his further retention in such institution because of his dangerousness, he
				shall apply during the period of retention authorized by the last order of the
				court for an order authorizing the continued retention of such patient. The
				provisions of this chapter which apply to applications for orders authorizing
				the retention or further continued retention of a patient in a hospital or a
				school shall apply except that, in addition to the need for retention for
				mental illness or mental retardation, the question of the continued
				dangerousness of such patient shall be determined. If it be determined that the
				patient is no longer in need of retention or is no longer dangerous, the court
				may order the discharge of the patient or it may order the transfer of the
				patient to a facility in the department.
(f) Any court order of commitment or court order authorizing
				retention or continued retention pursuant to this section is subject to review
				in accordance with section 31.35 of this chapter in the case of a mentally ill
				person or in accordance with section 33.35 of this chapter in the case of a
				mentally retarded person.
(g) Orders for commitment or authorizing retention pursuant to
				this section shall not be deemed as, or received in any court in evidence of,
				the commission of a crime by the patient so committed nor shall such commitment
				be deemed or considered as punishment for a crime.
(h) The costs necessarily incurred, under this section, in
				determining the dangerousness of such patient, including fees of the examiners,
				fees of the medical witnesses, and any other necessary expenses allowed by the
				court, shall be a charge upon the county from which such person was originally
				certified, but in the city of New York, the court shall order such costs
				audited and allowed by the comptroller from the court fund and charged to the
				proper county within the said city.
(i) During the pendency of such proceeding the court may
				forthwith order the commitment of such allegedly dangerous patient to an
				appropriate institution in the department of correction upon petition and the
				affidavit of two examining physicians that the director of the hospital or
				school is not able to properly care for such patient at the facility where he
				is confined and that such patient is in need of immediate treatment.
(j) The notices provided for herein may be served by registered
				mail on all persons required to be served other than the allegedly dangerous
				patient.
FORM 476 DMH (1/73) PAGE 1A
STATE OF NEW YORK - DEPARTMENT OF MENTAL HYGIENE
FORMS FOR THE COURT COMMITMENT OF
CERTAIN DANGEROUSLY MENTALLY DISABLED PATIENTS
INSTRUCTIONS
Upon determination by the Director of a Department of Mental
				Hygiene facility that a patient in his facility is so dangerous that he should
				be committed to an institution in the Department of Correctional Services, the
				Director may immediately proceed to complete Sections Two and Three of this
				form, upon the verbal order of the Commissioner of Mental Hygiene or his duly
				authorized designee.
Exact copies of those sections may be served upon the patient
				and the Mental Health Information Service prior to receipt of the
				Commissioner's written order (Section 1). However, before this application is
				submitted to the Court, the Commissioner's written order on Form 476 DMH, Page
				1, must be received and attached to the face of this form, and the Affidavit of
				Service of Notice (Section 4) must be completed.
This form, with the Commissioner's written order attached, must
				be submitted to the appropriate Court along with the attached two blank copies
				of Form 476A DMH, "Certificate of Examining Physician". Detach and save the
				attached copy of Form 476B DMH for later submission to the Court along with the
				completed Certificates of Examination.
If a Forthwith Commitment is desired, Form 476C DMH must be
				completed by the Director and two physicians on the staff of the Mental Hygiene
				facility, and may be submitted to the Court along with the Forms 476 and 476A.
				Form 476C DMH cannot be submitted to the Court prior to receipt of the written
				Order of the Commissioner and the submission to the Court of the completed Form
				476 DMH.
Image
Image
Image
Image
Image
Image
Image
Image
Image
FORM 476B DMH (1/73) PAGE 3
SECTION 3
AFFIDAVIT OF SERVICE (OF NOTICE OF PETITION AND THE
				PETITION)
STATE OF NEW YORK
COUNTY OF________
________ being duly sworn, says that he is over 18 years of
				age, and that on the ________ day of ________, 19________, at ________he served
				the foregoing Notice of Petition, and Petition upon the patient,
(PATIENT) and upon
(NAME OF RELATIVE OR FRIEND)
the
(STATE RELATIONSHIP) of
(PATIENT)
and upon the Mental Health Information Service by delivering a
				true copy of said Notice and Petition personally to the said patient and
				________, and serving the same by registered mail upon the Mental Health
				Information Service and ________. He further says that be knew the persons
				served, as aforesaid, to be
disabled patient, and
(NAME OF RELATIVE OR FRIEND) to be
the
(STATE RELATIONSHIP) of the person mentioned and
described in the said application.
Sworn to before this ________
day of ________, 19________
(OFFICIAL TITLE)
(SIGNATURE OF SERVER OF NOTICE)
Image
FORM 476B DMH (1/73) PAGE 5
SECTION 5
AFFIDAVIT OF SERVICE OF ORDER OF HEARING
STATE OF NEW YORK
COUNTY OF________
________, being duly sworn, says that he is ever 18 years of
				age, and that on the ________ day
if ________ 19________, at ________ he served the foregoing
				ORDER OF HEARING upon the
patient,
and ________, the persons directed to be served in the said
				Order of Hearing, and upon the Mental Health Information Service by delivering
				a true copy of said ORDER personally
to
(PATIENT) and ________, and by serving the same by registered
				mail
upon the Mental Health Information Service and ________. He
				further says that he knew the persons specified in the said Order.
Sworn to befor me this ________
day of ________, 19________
(OFFICIAL TITLE)
(SIGNATURE OF SERVER OF NOTICE)
Image
Image
FORM 476B DMH (1/73)
ORDERED, that the sum of $ ________ be and the same is hereby
				allowed and awarded to
________, M.D., and the sum of $ ________ be and the same is
				hereby allowed and awarded to
________, M.D., for their fees and expenses as examining
				physicians, and it appearing that the
said patient, ________, was admitted to
(MENTAL HYGIENE FACILITY
from ________ County,
it is further:
ORDERED, that the fees and costs aforesaid be audited and
				allowed by:
(Select one of the following:
(a) ________ County
OR
(b) the Comptroller of the City of New York from the court fund
				and charged to ________ County within the said City.
DATED ________, 19________ (Signature) ________
____________
(PRINT NAME TO BE SIGNED)
Justice or Judge of
____________
(COURT)
Statutory authority: Mental Hygiene Law,
				  §29.01