Welf. & Inst. Code, § 6253

Wherever provision is made in this code for court-appointed medical examiners to make and sign a certificate showing the facts of an examination in the case of a person alleged to be subject to judicial commitment, the certificate shall be in substantially the following form: In the Superior Court of the State of California for the County of ________

In the Superior Court of the State of California for the County of ________

______

The People For the Best Interest and Protection of ______, ⎫ ⎪ ⎪ ⎪ Certificate of Medical Examiners

as a ______ and ⎬

⎪

Concerning ______, ⎪

and ______, ⎪

______Respondents ______ ⎪ ⎭

We, Dr. ________ and Dr. ________, medical examiners in the County of ________, duly appointed and certified as such, do hereby certify under our hands that we have examined ________, alleged to be a ________, and have attended before a judge of said court at the hearing on the petition concerning said person, and have heard the testimony of all witnesses, and, as a result of the examination, have testified under oath before the court to the following facts concerning the alleged ____________:

Name ______ Address ______ Age ______ Sex ______ Occupation ______ Marital status ______ (Single, married, widowed, divorced) Religious belief ______ Pertinent case history ______ ______ ______ General physical condition ______ ______ Present mental status ______ ______ ______ Laboratory reports (if any) ______ ______ Tentative diagnosis of mental health ______ ______ ______ Recommendation for disposition or supervision, treatment and care ______ ______ ______ Reason for the recommendation ______ ______ ______ ______

Date ________________

____________Medical Examiner ____________Medical Examiner