PEACE OFFICER'S NOTIFICATION OF EMERGENCY DETENTION.

(a) A peace officer shall immediately file with a facility a notification of emergency detention after transporting a person to that facility in accordance with Section 573.001. Emergency medical services personnel of an emergency medical services provider who transport a person to a facility at the request of a peace officer made in accordance with a memorandum of understanding executed under Section 573.005 shall immediately file with the facility the notification of emergency detention completed by the peace officer who made the request.

(b) The notification of emergency detention must contain:

(1) a statement that the officer has reason to believe and does believe that the person evidences mental illness;

(2) a statement that the officer has reason to believe and does believe that the person evidences a substantial risk of serious harm to the person or others;

(3) a statement that the officer has reason to believe and does believe that the risk of harm is imminent unless the person is immediately restrained;

(4) a statement that the officer's beliefs are derived from specific recent behavior, overt acts, attempts, or threats that were observed by or reliably reported to the officer;

(5) a detailed description of the specific behavior, acts, attempts, or threats; and

(6) the name and relationship to the apprehended person of any person who reported or observed the behavior, acts, attempts, or threats.

(c) The facility where the person is detained shall include in the detained person's clinical file the notification of emergency detention described by this section.

(d) The peace officer shall provide the notification of emergency detention in substantially the following form:

Notification--Emergency Detention NO. ____________________ DATE:_______________ TIME:_______________

THE STATE OF TEXAS

FOR THE BEST INTEREST AND PROTECTION OF:

______________________________________

DOB:_____________ RACE:______________ GENDER:_______________ PHONE NUMBER:______________ ADDRESS:________________________

NOTIFICATION OF EMERGENCY DETENTION

Now comes _____________________________, a peace officer with (name of agency) _____________________________, of the State of Texas, and states as follows:

□ I have reason to believe and do believe that (name of person to be detained) __________________________ evidences mental illness;

□ I have reason to believe and do believe that the above-named person evidences a substantial risk of serious harm to himself/herself or others based on the person's behavior or evidence the person is experiencing severe emotional distress and deterioration to the extent the person cannot remain at liberty; and

□ I have reason to believe and do believe that the risk of harm is imminent unless the above-named person is immediately restrained.

1. My above-stated beliefs are based upon the following recent behavior, severe emotional distress and deterioration, overt acts, attempts, statements, or threats observed by me or reliably reported to me (may use attachments to report additional information):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. The names, addresses, phone numbers, and relationship to the above-named person of those persons who reported or observed recent behavior, acts, attempts, statements, or threats of the above-named person are (if applicable):

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ADULT 65 YEARS OF AGE OR OLDER? □ YES □ NO If yes, age: ___________

CHILD 17 YEARS OF AGE OR YOUNGER? □ YES □ NO If yes, age: ___________

FOR A CHILD 17 YEARS OF AGE OR YOUNGER (if yes):

My belief the child is at risk of imminent serious harm unless immediately removed from the parents' custody is based on the above-stated facts showing the parents or guardians are presently unable to protect the child from imminent serious harm.

□ I provided notice to the child's parents or guardians of my intention to file this notification.

□ I was not able to provide notice to the child's parents or guardians of my intention to file this notification because: ________________________________________________________________

________________________________________________________________

Parent/Guardian Contact Information: ____________________________

________________________________________________________________

USE OF RESTRAINT

Was the person physically restrained in any way? Yes □ No □

If yes, reason for physical restraint? □ Officer Safety

□ Person's Safety □ Other ____________________

CALL ORIGINATED AT:

□ Public Area □ Residence □ School/University

□ Group Home □ Hospital

□ Other________________________________________

OBSERVATIONS/HISTORY

If YES to any question below, provide additional information:

YES NO UNKNOWN NOTES

Harm to self or stating an intention to harm self?

Previous attempt to commit suicide?

Harm to others or stating an intention to harm others?

Previous serious harm or injury to others?

Previous psychiatric hospital treatment?

Reported mental health diagnosis?

Prescribed psychiatric medications?

Current psychiatric medications taken?

Sleeping difficulty?

Substance use disorder?

TRANSPORTED TO:

□ Hospital/Emergency Room □ Mental Health Facility

□ Other _______________________

For the above reasons, I present this notification to seek temporary admission to the (name of facility) _________________________ inpatient mental health facility or hospital facility for the detention of (name of person to be detained) __________________________ on an emergency basis.

PEACE OFFICER'S PRINTED NAME: ___________________________________

BADGE NO. _____________________

PEACE OFFICER'S SIGNATURE _______________________________________

Address: _________________________ Zip Code: ____________________

Telephone: ______________________

SIGNATURE OF EMERGENCY MEDICAL SERVICES PERSONNEL (if applicable)

_________________________ PRINTED NAME OF PERSONNEL: _____________

Address: _________________________ Zip Code: ____________________

Telephone: ______________________

A mental health facility or hospital emergency department may not require a peace officer or emergency medical services personnel to execute any form other than this form as a predicate to accepting for temporary admission a person detained by a peace officer under Section 573.001, Health and Safety Code.

(e) A mental health facility or hospital emergency department may not require a peace officer or emergency medical services personnel to execute any form other than the form provided by Subsection (d) as a predicate to accepting for temporary admission a person detained by a peace officer under Section 573.001 and transported by the officer under that section or by emergency medical services personnel of an emergency medical services provider at the request of the officer made in accordance with a memorandum of understanding executed under Section 573.005.

(f) A peace officer who transports an apprehended person to a facility under Section 573.001(d)(1) or emergency medical services personnel of an emergency medical services provider who transports a person to a facility under Section 573.001(d)(2):

(1) is not required to remain at the facility while the apprehended person is medically screened or treated or while the person's insurance coverage is verified; and

(2) may leave the facility immediately after:

(A) the person is taken into custody by appropriate facility staff; and

(B) the notification of emergency detention required by this section is provided to the facility.