Printable Maryland Admission Template
The Maryland Admission form is a crucial document designed for individuals seeking voluntary admission to a behavioral health facility. This form serves as an official request for care or treatment of a mental disorder, as outlined in the state's Health-General Article. It requires the applicant to provide personal information, including their name, address, date of birth, and contact details. Additionally, the form must be signed by the applicant, indicating their understanding of the nature of the request for treatment. A vital component of the admission process is the endorsement from a licensed physician or psychologist. This endorsement confirms that the individual has a mental disorder that is treatable and that they possess the capacity to understand their request for treatment and to provide ongoing consent for their stay. The form also emphasizes the importance of non-discrimination in the provision of services, in compliance with federal civil rights laws. It is essential for applicants to be aware of the specific criteria for admission, particularly regarding age and the necessity of a geriatric evaluation for individuals over 65. The form not only facilitates the admission process but also ensures that the rights and needs of the individual are prioritized throughout their treatment journey.
Maryland Admission Preview
State of Maryland – Department of Health and Mental Hygiene
BEHAVIORAL HEALTH ADMINISTRATION
Catonsville, MD 21228
APPLICATION FOR VOLUNTARY ADMISSION
To the Administrative Head of:
Name of Facility
I hereby apply for voluntary admission to your facility for the care or treatment of a mental disorder pursuant to the provisions of
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Printed Name of Applicant |
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Signature of Applicant |
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Address |
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Date of Birth |
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Telephone Number |
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PHYSICIAN’S OR PSYCHOLOGIST’S ENDORSEMENT |
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I have examined |
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The individual has a mental disorder;
The mental disorder is susceptible to care or treatment;
The individual understands the nature of the request for treatment;
The individual is able to give continuous assent to retention by the facility; and
The individual is able to ask for release.
I certify that I am duly licensed to practice medicine in the State of Maryland, pursuant to the Health Occupations Article,
I certify that I am licensed under the Health Occupations Article, Title 18, Annotated Code of Maryland, to practice psychology in the State of Maryland.
Printed Name of Physician or Psychologist |
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Signature of Physician or Psychologist |
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Address |
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Phone Number |
Date |
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The services and programs of the Department of Health and Mental Hygiene are provided on a
Application for Voluntary Admission must be on this form
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DHMH #4 (Revised September 2, 2014) |
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(a)In general. — Application for voluntary admission of an individual to a facility may be made under this section by the individual, if the individual is 16 years old or older.
(b)Application. — The applicant shall:
(1)Submit a formal, written application that contains the personal information and is on the form required by the Administration; or
(2)Informally request admission.
(c)Admission limitations — In general. — A facility may not admit an individual under this section unless:
(1)The individual has a mental disorder;
(2)The mental disorder is susceptible to care or treatment;
(3)The individual understands the nature of the request for admission;
(4)The individual is able to give continuous assent to retention by the facility; and
(5)The individual is able to ask for release.
(d)Admission limitations — Individuals 65 or older. — (1) In addition to the limitations in subsection (c) of this section, a State facility may not admit an individual who is 65 years old or older unless a geriatric evaluation team determines that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual.
(2)If admission is denied because of the determination of the geriatric evaluation team, the team shall;
(i)Inform the individual; and
(ii)Help the individual obtain the less restrictive form of care or treatment that the geriatric evaluation team finds would be adequate for the needs of the individual.
(a)Informal request. — An individual who is admitted voluntarily to a facility, on an informal request, may leave the facility at any time between 9 a.m. and 4 p.m., unless the admission status of the individual has been changed to an involuntary admission.
(b)Formal applications — An individual who has been admitted voluntarily, under a formal written application, may not be held for more than 3 days after the individual asks for release, unless the admission status of the individual has been changed to an involuntary admission.
(c)Formal applications — Minors. — A minor who has been admitted voluntarily, on the application of a parent or guardian of the minor, may not be held for more than 3 days after the applicant for the admission asks for release, unless the admission status of the minor has been changed to an involuntary admission.
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DHMH #4 (Revised September 2, 2014) |
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Form Attributes
| Fact Name | Details |
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| Governing Law | The application is governed by Health-General Article, §10-609, Annotated Code of Maryland. |
| Eligibility Age | Individuals aged 16 years or older can apply for voluntary admission. |
| Application Requirement | A formal, written application must be submitted using the specified form. |
| Admission Criteria | The individual must have a mental disorder that is treatable and must understand the nature of the request. |
| Assent to Retention | The applicant must be able to give continuous assent to being retained in the facility. |
| Release Request | Applicants must have the ability to request their release from the facility. |
| Special Consideration for Seniors | For individuals 65 or older, a geriatric evaluation team must determine the necessity of admission. |
| Informal Admission | Individuals admitted informally can leave between 9 a.m. and 4 p.m. unless their status changes. |
| Time Limit for Release | Those admitted formally cannot be held for more than 3 days after requesting release. |
| Non-Discrimination Policy | Services are provided on a non-discriminatory basis, in compliance with the Civil Rights Act of 1964. |
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