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Viewing: Form 1013 and Form 2013 – Certificate Authorizing Transport to Emergency Receiving Facility and Report of Transportation, 01-110

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Current Status: Active PolicyStat ID: 1136700

Form 1013 and Form 2013 – Certificate Authorizing Transport to Emergency Receiving Facility and Report of Transportation, 01-110

FULL IMPLEMENTATION DATE - December 1, 2014

APPLICABILITY

Crisis Stabilization Units, Community Providers of Mental Health Services, DBHDD State Hospitals and Emergency Departments of Community Hospitals

POLICY

DBHDD Form 1013 is utilized to initiate transportation to an emergency receiving facility, where the individual would be evaluated for admission on the basis of mental illness and substantial risk of imminent harm to self or others.

DBHDD Form 2013 is utilized to initiate transportation to an emergency receiving facility, where the individual would be evaluated for admission on the basis of substance use disorder and substantial risk of imminent harm to self or others.

This opinion of the person completing the 1013 or the 2013 is based on (1) recent overt acts, (2) recent expressed threats, or (3) an imminently life-endangering crisis because of the person’s inability to care for self. Contacts with the Emergency Receiving Facility (ERF) and transportation of the individual to the ERF are completed in accordance with these procedures.

PROCEDURES

  1. WHO CAN COMPLETE FORMS 1013 OR 2013
    1. The Form 1013 (Attachment A) and the Form 2013 (Attachment B) can be completed by any of the following: 
      1. Licensed Physician
      2. Licensed Psychologist
      3. Licensed Clinical Social Worker (LCSW)
      4. Licensed Professional Counselor (LPC)
      5. Advanced Practice Registered Nurse (APRN) Clinical Nurse Specialist (CNS) in Psychiatric/Mental Health
      6. APRN under protocol
      7. Physician's Assistant (PA) under protocol
  2. STEPS PRIOR TO COMPLETION OF THE FORM 1013 OR THE FORM 2013
    1. These instructions reference the procedure to be followed for either the Form 1013 and the Form 2013.  The reader should substitute the appropriate disorder specific terminology as it applies to the form they are completing.
    2. Determine that the individual does in fact meet criteria of mental illness or substance use disorder AND ‘imminent risk’ as specified on the Form 1013 or the Form 2013.
    3. Contact the Emergency Receiving Facility (ERF); provide clinical information to the facility and determine if the facility has the capacity to admit the individual, if admission is necessary.
    4. Providing the clinical information will help determine if the individual has signs or symptoms of a medical condition that would warrant urgent medical intervention prior to transport to the ERF. Individuals should not be referred to Emergency Rooms for ‘medical clearance,’ but for a specific complaint that would normally be seen in an emergency department (chest pain, delirium, shortness of breath). For more information re: MEDICAL CLEARANCE see Medical Evaluation Guidelines and Exclusion Criteria for Admissions to State Hospitals and Crisis Stabilization Units, 03-520.
  3. STEPS IN COMPLETION OF CERTIFICATE AUTHORIZING TRANSPORT (page 1 of Form 1013 or Form 2013)
    1. Fill in the County where the Individual is currently located (not the county where the ERF is located).
    2. Fill in the name of the patient and the date/time of the evaluation. The evaluation must have been within 48 hours of the signing of the Form 1013 or the Form 2013.
    3. Determine if, In your opinion, this Individual appears to require involuntary treatment in that he/she appears to be mentally ill or has a substance use disorder AND then check one or both of the following:
      • ‘A’ - if the individual presents a substantial risk of imminent harm to self or others as manifested by recent overt acts or recent expressed threats of violence which present a probability of physical injury to self or to other persons
      • ‘B’ for 1013 - if the individual appears to be so unable to care for his/her own physical health and safety as to create an imminently life-endangering crisis. OR
      • 'B' for 2013 - if the individual is incapacitated by alcoholic beverages, drugs, or other substances on a recurring basis.
    4. Complete the section that reads: At the time of my evaluation, the conditions checked below were present:      
      • This Individual appears to be mentally ill or has a substance use disorder. My opinion is based on the following observations: Describe your observations supporting your opinion that the person is mentally ill or has a substance use disorder (e.g., actively hallucinating, disorganized speech, manic, etc or, is incapacitated by alcoholic beverages, drugs or other substances).
    5. Check the appropriate box(es) to indicate that this Individual:                                       
      • Has committed/expressed recent overt acts/threats towards others.                         
      • Has committed/expressed recent acts/threats of violence to self.                               
      • Presents an imminently life endangering crisis to self because he/she is unable to care for his/her own health and safety.  For example: (e.g., threatened to cut wrist, threatened to kill relative, etc)
    6. Fill in date/time and sign the form to include credentials (M.D., D.O., Ph.D., LCSW, LPC, APRN, CNS, PA)
    7. Complete bottom of form after Emergency Receiving Facility (ERF) agrees to accept patient for evaluation. This does not have to be done by the signer of the form.
  4. STEPS IN COMPLETION OF REPORT OF PEACE OFFICER OR OTHER PERSON PROVIDING TRANSPORTATION (page 2 of Form 1013 or Form 2013)
    1. Fill in name of the county where person was transported.
    2. Fill in name of person transported.
    3. Fill in name of the Emergency Receiving Facility (ERF) where the person was taken. 
    4. Complete the ‘time/date’ of pick up, location and observations during transit. 
    5. Fill in name/address of family or others who were present when the individual was taken into custody (if applicable - law enforcement only). 
    6. Fill in comments or information from family or others who have personal knowledge of individual (if applicable). 
    7. Indicate if physical restraints were used in transit and the reasons for the restraints. 
    8. Add description of the individual’s obvious physical condition (apparent injuries, distress). 
    9. Add other information, if applicable. 
    10. Indicate who provided the transportation. 
    11. Sign/date form and give to Emergency Receiving Facility. 
  5. FURTHER INFORMATION
    1. Questions that have been asked about this process are addressed in Frequently Asked Questions (FAQ) Regarding the Form 1013 and Form 2013 (Attachment C).  Non-urgent questions about Form 1013 and Form 2013 may be sent to PolicyQuestions@dbhdd.ga.gov.

RELATED POLICIES

Criteria for Mental Health Admissions of Adults to DBHDD Hospitals03-502

Medical Evaluation Guidelines and Exclusion Criteria for Admissions to State Hospitals and Crisis Stabilization Units, 03-520

Legal Status for DBHDD Hospitals, 24-106

LEGAL REFERENCES

O.C.G.A. § 37-3-1, 37-3-41, 37-3-101, 37-7-1, 37-7-41 & 37-7-101

Attachments:

Approval Signatures

Approver Date
Joetta Prost, Ph.D.: DBHDD Policy Director 12/1/2014
Amy Howell: General Counsel 11/10/2014
Emile Risby, M.D.: Medical Director 10/23/2014
Joetta Prost, Ph.D.: DBHDD Policy Director 10/23/2014
Older Version Approval Signatures
Approver Date
Joetta Prost, Ph.D.: DBHDD Policy Director 12/1/2014
Amy Howell: General Counsel 11/10/2014
Emile Risby, M.D.: Medical Director 10/23/2014
Joetta Prost, Ph.D.: DBHDD Policy Director 10/23/2014
Older Version Approval Signatures
Joetta Prost, Ph.D.: DBHDD Policy Director 6/30/2014
Amy Howell: General Counsel 6/30/2014
Emile Risby, M.D.: Medical Director 6/17/2014
Joetta Prost, Ph.D.: DBHDD Policy Director 6/11/2014
Joetta Prost, Ph.D.: DBHDD Policy Director 3/21/2012
Emile Risby, M.D.: Medical Director 3/21/2012