Form OMH486 (06/cl)

APPLICATION FOR HOSPITAL EXAMINATION AFTER FAILURE TO COMPLY WITH ORDER FOR
ASSISTED OUTPATIENT TREATMENT	Person's Name (Last, First, M.I.)

Sex	Date of Birth	

Address	
GENERAL INFORMATION	

Section 9.60(n) of the Mental Hygiene Law (MHL) sets forth circumstances under which a person who is subject to an order for assisted outpatient treatment (AOT) may be taken into custody and transported to a hospital for evaluation to determine if the person should be admitted for psychiatric care and treatment. MHL Section 9.63 provides that, in carrying out such transportation, appropriate attempts shall be made to elicit the cooperation of the person to be transported prior to resorting to compulsory means of transportation.

The procedure established in section 9.60(n) begins with a determination by a physician that the person has failed or has refused to comply with the AOT order and that efforts were made to solicit compliance with the order. In addition, the physician must conclude that the person MAY:	

(i)	be in need of involuntary care and treatment in a hospital providing inpatient services for persons with mental illness, pursuant to MHL Section 9.27(see FORMS OMH 471 and 471 A),
-OR-
(ii)	have a mental illness for which immediate observation, care and treatment in a hospital is appropriate
and which is likely to result in serious harm to self or others, pursuant to MHL Sections 9.39 or 9.40 (see FORMS OMH 474 and 476).

"In need of involuntary care and treatment" means that a person has a mental illness for which care and treatment as a patient in a hospital is essential to such person's welfare and whose judgment is so impaired that he is unable to understand the need for such care and treatment (see MHL Section 9.01).

"Likely to result in serious harm" means (a) a substantial risk of physical harm to the person as manifested by threats of or attempts at suicide or serious bodily harm or other conduct demonstrating that the person is dangerous to himself or herself, or (b) a substantial risk of physical harm to other persons as manifested by homicidal or other violent behavior by which others are placed in reasonable fear of serious physical harm (see MHL Section 9.01).

Upon such a determination by a physician, a request is made by the physician to: (1) a director of an AOT pro-. gram; (2) the designee. of the AOT program director, or (3) a physician designated by the director of community services under MHL Section 9.37, to direct that the person be taken into custody and transported to a hospital for evaluation. (see Part A below). The director, designee or physician appointed pursuant to section 9.37 then determines whether to direct that the person be taken into custody and transported to a hospital (see Part B below). Under MHL Section 9.60(n), an approved mobile crisis outreach team, an ambulance service, or a police officer or an appropriate peace officer can be directed to take the person into custody for transport to a hospital. The hospital to which the person is transported must be one operating an AOT program or one authorized by the county director of community services to receive persons subject to AOT orders.

A physician at the receiving hospital shall evaluate the person's need for involuntary care and treatment
within a 72 hour period from receipt at the hospital. If the physician at the hospital confirms that the person needs involuntary care and treatment, the person shall be admitted as a patient.	
PART A I REQUEST FOR ASSISTED OUTPATIENT TO BE EXAMINED	
Pursuant to the authority granted to me under Section 9.60(n) of the Mental Hygiene Law (MHL) ,
I,	Physician., hereby request that	be removed to	

, a hospital for examination.	
'-'

Page2

In support of this request, I hereby state with respect to the above-named person that:
1.	In my clinical judgment
a.	this person has failed or refused to comply with the assisted outpatient treatment ordered by the court;
b.	efforts were made to solicit compliance by this person with the treatment ordered by the court; and
c.	this person (Check appropriate box),
may be in need of involuntary care and treatment in a hospital providing inpatient services for
mental illness pursuant to MHL Section 9.27, or
may have a mental illness for which immediate observation, care and treatment in a hospital is
appropriate and which is likely to result in serious harm to self or others pursuant to MHL Sections 9.39 or 9.40.
2.	To the best of my knowledge and belief, the facts stated above and the information contained herein are true.	

Signature of Physician	

	

	
								      Day/Month		Year

PART B	CUSTODY/TRANSPORT OF PERSON SUBJECT TO ASSISTED OUTPATIENT TREATMENT ORDER

Pursuant to MHL section 9.60(n),I hereby direct that (check one)
          The                                                                                          ambulance service, or	
	An approved mobile crisis outreach team or	
                                                                Peace Officers/Police officers of:	
	(Department/Location)
take the above-named person into custody and transport him/her to the following hospital (as designated by the Director of Community Services):
Name of Hospital:	
Address of Hospital:	

Signed:______________________________________________________________Date__________________

AOT Position/Capacity: (Check One)                            __________ Director Of Assisted Outpatient Treatment
                                                                                        
                                                                                       __________ Designee of Director of AOT

                                                                                       __________ Physician designated pursuant to MHL 9.37