• DSAMH Home
• About DSAMH
  • Agency Overview
  • Contact Us
  • FAQ
  • DSAMH Organization Chart
  • Treatment Providers
• Consumer Outreach
• Prevention
  • Archival Indicators
  • DUI Offender Education
  • Epidemiology Report
  • Guiding Principles and Guidelines
  • Prevention Centers
  • Prevention Dimensions
  • Risk and Protective Model
  • SHARP Reports
• Treatment
  • Case Management
  • Consumer Information
  • Mental Health
  • PASRR
  • Substance Abuse
• Utah State Hospital
• Reports & Statistics
  • Annual Reports
  • Archival Indicators
  • Consumer Satisfaction
  • DORA
  • Drug Information
  • Epidemiology Report
  • Fact Sheets
  • Higher Education Survey
  • Legislative Reports
  • Mental Health and Substance Abuse Block Grant Applications
  • Mental Health Involuntary Commitment Act
  • Morbidity and Mortality in People with Serious Mental Illness
  • Outcome Reports
  • SHARP Reports
  • Suicide Prevention Plan
  • Utah Frontiers Project
  • Utah's School Behavioral Health Services Implementation Manual
• Education/Training
  • Beverage Server Training (On Premise)
  • Designated Examiner
  • DUI Offender Education
  • EASY - Eliminate Alcohol Sales To Youth (Off Premise)
  • Forensic Examiner
• Contract/Monitoring
• UBHPAC
• Contact Us

Civil Commitment Forms - Adult

Form	Description	Statute	Updated	DE Req?
Admission (Voluntary)
Application for Voluntary Admission to Local Mental Health Authority Form 35-1	For individuals 18 years and older to admit self to LMHA	62A-15-625	2012	No
Request for Release from Admission to Local Mental Health Authority Form 31-1	Voluntary patient may use this to request release (Release may be postponed up to 48 hours)	62A-15-627	2012	No
Notice of Denial of Request for Release from Local Mental Health Authority Form 31-2	LMHA notice to patient denying request for release	62A-15-627	2012	No
Application (Involuntary Initial)
Application for Order of Involuntary Commitment (2 pages) Form 36-1	Form used to initiate involuntary civil commitment proceedings (Two sided. Must be notarized.)	62A-15-631(a)(b)	2012	Yes, but not required
Report of Local Mental Health Authority/Designee of Examination Upon Admission Form 36-8	Used as part of the application for civil commitment process	62A-15-631(3)	2012	No
Order to Determine Existing Facts and Report of Existing Facts (2 pages) Form 36-2	The court may require this information before issuing an order of detention (Court Form 1st Page)	62A-15-631(2)	2012	No
Order for Commitment and/or Detention Pending Hearing and/or Examination Form 36-5	Court order which allows individual (proposed patient) to be detained prior to hearing (Court Form)	62A-15-631(3)	2012	No
Order Fixing Day and Notice of Hearing Form 36-9	Court notice to proposed patient and appropriate others of pending hearing (Court Form)	62A-15-631(5)	2012	No
Notice to Patient of Commencement of Proceedings For Involuntary Commitment Form 36-3	Court notice to proposed patient that an application for civil commitment has been filed and that designated examiners will be appointed (Court Form)	62A-15-631(4)	2012	No
Order Appointing Designated Examiners and Report of Examination Form 36-6	LMHA uses form to discharge a child from commitment	62A-15-631(8)(c)	2012	No
Order Appointing Legal Counsel Form 36-18	Court order appointing legal counsel for proposed patient (Court Form)	62A-15-631(9)(a)	2012	No
Designated Examiner Report to the Court (3 pages) Form 36-19	Designated Examiner report to court (AKA Report of Examination by Designated Examiner and Report of Designated Examiner)	62A-15-631(10) and 62A-15-632	2012	Yes
Notice to Drop Commitment Proceedings Prior to a Hearing Form 36-15	LMHA's can use this form to discontinue the civil commitment process prior to the hearing	62A-15-631(8)(c)	2012	No
Application (Emergency)
Emergency Application for Involuntary Commitment Without Certification (The Pink Sheet) (2 pages) Form 34-2	Peace officers or mental health officer may use this form to temporarily hold an individual for 24 hours (Two sided. Printed on pink paper)	62A-15-629 (2) and (3)	2012	No
Emergency Application for Involuntary Commitment With Certification (The Blue Sheet) (2 pages) Form 34-1	Allows an individual to be temporarily held for 24 hours. Requires certification by MD or DE (Two sided. Printed on blue paper.)	62A-15-629	2012	Yes, but not required
Commitment (Orders)
Initial Findings and Order of Commitment Form 36-10	Court order on initial civil commitment hearing (Court Form)	62A-15-631(10)	2012	No
Commitment (Continuations)
Notice of Continuation of Indeterminate Commitment Form 36-14	LMHA uses this form for review of commitment criteria for patients under an indeterminate commitment (Must be completed every six months)	62A-15-631(11)(c)	2012	No
Commitment (Release)
Notice of Discharge From Judicial Order of Commitment Form 42	LMHA can discharge patient from order of commitment	62A-15-636	2012	No
Notice of Conditional Release Form 43-1	LMHA uses this form to notify court that patient has been conditionally released to a less restrictive setting and has agreed to tx plan	62A-15-637	2012	No
Transfers
Notice of Transfer of Patient Form 41	LMHA uses this form to notify court that a committed patient has been transferred to a different treatment unit	62A-15-637(1)	2012	No
Order of Placement Into a More Restrictive Environment (2 pages) Form 43-2	LMHA can place a patient in a more restrictive setting (Patient may request a court hearing within 30 days of placement into a MRE)	62A-15-637(2)	2012	No
Findings and Order Upon Return to a More Restrictive Environment Form 43-3	Court order which agrees or disagrees with LMHA placing a patient into a MRE (Court Form)	62A-15-637	2012	No
Order of Transfer Form 36-13	Allows Court to transfer the case to another district court (Court Form)	62A-15-631(7)	2012	No
Additional Forms
Findings and Order Upon Review Hearing Form 36-11	Court order on review civil commitment hearing (Court Form)	62A-15-631(11) and 632	2012	No
Order of Dismissal Form 36-12	Court order of dismissal (Court Form)	62A-15-631(10)	2012	No