Cal. Welf. and Inst. Code § 5262
A second notice of certification for imminently suicidal persons is required for all involuntary 14-day intensive treatment, pursuant to this article, and shall be in substantially the following form:
To the Superior Court of the State of California for the County of ______ |
The authorized agency providing 14-day intensive treatment, County of _________, has custody of: _________ |
Name ____________ |
Address ____________ |
Age ____________ |
Sex ____________ |
Marital status ____________ |
Religious affiliation ____________ |
The undersigned allege that the above-named person presents an imminent threat of taking his own life. This allegation is based upon the following facts: |
This allegation is supported by the accompanying affidavits signed by ____________. |
The above-named person has been informed of this allegation and has been advised of, but has not been able or willing to accept referral to, the following services: |
We, therefore, certify the above-named person to receive additional intensive treatment for no more than 14 days beginning this day of (Month), 19__, in the intensive treatment facility herein named ________. |
We hereby state that a copy of this notice has been delivered this day to the above-named person and that he has been clearly advised of his continuing legal right to a judicial review by habeas corpus, and this term has been explained to him. |
(Date) |
Signed Countersigned _____ Representing intensive treatment facility _____ |
Ca. Welf. and Inst. Code § 5262