REQUEST TO RETURN ESCAPEE OR CONDITIONAL RELEASEE

1 STATE OF NORTH CAROLINA REQUEST TO RETURN ESCAPEE OR CONDITIONAL RELEASEED epartment of Health and Human ServicesDivision of Mental Health, Developmental Disabilities, and Substance Abuse ServicesDISTRIBUTION WHEN REQUEST TO RETURN IS ISSUED:Nursing Staff: HIM (original copy) Official placing patient on detainer Initial examiner if involuntarily committed Area program (if appropriate) Next of kin/legally responsible partyAny law enforcement office notified Clerk of Superior Court in county of commitmentDMH 5-82-02 REQUEST TO RETURN ESCAPEE OR CONDITIONAL RELEASEER evised September 2001 DATE: _____ TO: _____ FROM.

2 _____ (Sheriff/Law Enforcement Officer) (Facility) (Where Facility is Located)Patient s name: _____ Also known as_____ Hospital Number: _____ SS#: _____Last known home address: _____ Admit date: _____Hospital Unit/Bldg/Ward_____This is to notify you that the above named patient from _____County R ESCAPED on _____ (home county) R BREACHED THE CONDITION OF HIS/HER RELEASE ON _____The patient is.

3 RUnder involuntary commitmentR following being charged with a violent crime and found not guilty by reason of insanity (NGRI) orincapable of proceeding (HB 95)RA competent adult voluntarily admitted and in my opinion is reasonable foreseeable that:1) he/she may cause physical harm to others or himself;2) he/she may cause damage to property3) he/she may commit a felony or a violent misdemeanor; or4) the health or safety of the client may be endangered unless he/she is immediately returned tothe facilityRA minor or incompetent adult voluntarily admittedRAdmitted pending a judicial hearingRUnder CONDITIONAL release from the facilityRInvoluntarily committed or voluntarily admitted and under a DETAINER issued by Patient was last seen:Date:Time:Wearing:Location.

4 R Activity AreaR ClinicR Dining roomR GymR Work ActivityR Activity TripR CourtroomR ElevatorR HallwayR UnknownR BathroomR CourtyardR Grill/CanteenR Medical TransportR Other _____R BedroomR DayroomR GroundsR StairwayThe above named patient is to be taken into custody and returned to the above named facility pursuant to 122C-205. PATIENT IDENTIFYING INFORMATIONRace _____ Sex ___ Place of birth (state)_____ Date of birth _____ Age ____ Height _____ Weight _____Eye color _____ Hair color _____ Hair style _____ Skin tone _____Scars/Marks/Tattoos _____Facial features _____Build _____ Gait _____ Other distinguishing features _____Patient has vehicle at hospital R yes R no If yes, vehicle license number: _____ Vehicle lic state: _____Type of vehicle: _____ Vehicle year: _____ Vehicle make: _____ Vehicle style:_____ Vehicle color.

5 _____Dangerous to self R no R yes (specify) _____Dangerous to others: R no R yes (specify)_____Avoids people R no R yes Medical Conditions/Impairments:_____ Needs further treatment: R yes R noADDITIONAL INFORMATIONA dditional information that is reasonably necessary to assure the expeditious RETURN of the client and protect the patient and/orthe general public (including possible locations and contacts): _____Signature of Authorizing Physician Printed name Dat