Texas Health and Safety Code - HEALTH & SAFETY § 573.002. 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:

(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.  _______________________________ _______________________________  _______________________________     _______________________________  _______________________________  

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.
6. Was the person restrained in any way?  Yes □  No □
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):