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 _____
(Added by Stats. 1968, Ch. 1374.)
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