The Maryland Admission form is a crucial document used for the voluntary admission of individuals seeking care or treatment for mental disorders in Maryland facilities. This application, which adheres to the guidelines outlined in the Health-General Article, §10-609, ensures that the rights and needs of the individual are respected throughout the admission process. For those interested in seeking treatment, please consider filling out the form by clicking the button below.
The Maryland Admission form is a crucial document for individuals seeking voluntary admission to a mental health facility in the state. This form is designed to ensure that applicants provide essential personal information, such as their name, address, date of birth, and contact details. It requires the signature of the applicant, affirming their request for treatment. Additionally, a physician or psychologist must endorse the application, confirming that the individual has a mental disorder that can be treated and that they understand the nature of their request. This endorsement also verifies that the applicant is capable of giving continuous consent for their retention in the facility and can ask for their release. The form emphasizes the importance of non-discrimination in the admission process, adhering to civil rights laws. It is important to note that individuals must be at least 16 years old to apply, and specific criteria must be met for admission, particularly for those aged 65 and older. Overall, the Maryland Admission form serves as a structured pathway for individuals to access the mental health care they need while ensuring their rights and understanding are respected throughout the process.
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 Health-General Article, §10-609, Annotated Code of Maryland, which has been explained and provided to me (See law printed on reverse of this form.)
_________________________________________________
_____________________________________________
Printed Name of Applicant
Signature of Applicant
Address
Date of Birth
__________________________________________________
Telephone Number
Date
Time
PHYSICIAN’S OR PSYCHOLOGIST’S ENDORSEMENT
I have examined
, and I find that:
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, §14-305, Annotated Code of Maryland.
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
Signature of Physician or Psychologist
Phone Number
The services and programs of the Department of Health and Mental Hygiene are provided on a non-discriminatory basis and in compliance with Article VI of the Civil Rights Act of 1964. Any complaints regarding alleged discrimination may be filed in writing with the Director, Behavioral Health Administration, Spring Grove Hospital Center, 55 Wade Avenue, Dix Building, Catonsville, MD 21228 and the Office of Civil Rights, U.S. Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Philadelphia, PA 19106-3499.
Application for Voluntary Admission must be on this form [Health-General Article, §10-609(b)(1)]
DHMH #4 (Revised September 2, 2014)
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HEALTH-GENERAL ARTICLE
§10-609. Application by individual
(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.
§10-803. Voluntary admissions.
(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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Completing the Maryland Admission form is an essential step for individuals seeking voluntary admission to a facility for mental health treatment. This process requires careful attention to detail, as accurate information ensures that the application is processed efficiently. Below are the steps to fill out the form correctly.
Following these steps will help ensure that the Maryland Admission form is filled out correctly and submitted in a timely manner. Once submitted, the facility will review the application and proceed with the necessary steps for admission.
The Maryland Admission form is used to apply for voluntary admission to a facility for the care or treatment of a mental disorder. This application is in accordance with the Health-General Article, §10-609, of the Annotated Code of Maryland. It ensures that individuals seeking treatment are properly documented and that their rights and needs are addressed.
Individuals who are 16 years old or older can apply for voluntary admission using this form. The applicant must have a mental disorder that is susceptible to care or treatment and must be able to understand the nature of their request for admission.
The form requires the following information:
Additionally, the physician or psychologist must certify that the individual meets specific criteria related to their mental disorder and ability to provide consent.
Once the application is submitted, the facility will review it to determine if the individual meets the criteria for admission. If approved, the individual may be admitted for treatment. If the individual requests release, they cannot be held for more than three days unless their admission status changes to involuntary.
Yes, individuals who are 65 years old or older must undergo a geriatric evaluation. This evaluation determines if there are less restrictive forms of care or treatment available that would adequately meet their needs. If the evaluation finds that such options exist, the individual will be informed and assisted in obtaining them.
Individuals admitted voluntarily have the right to request their release at any time during designated hours. If they have submitted a formal application, they cannot be held for more than three days after requesting release, unless their status changes to involuntary admission. This protects their autonomy while ensuring they receive necessary care.
Incomplete Personal Information: Failing to provide all required personal details, such as the applicant's full name, address, and date of birth, can lead to delays or denial of the application.
Missing Signatures: Not signing the application or the physician's endorsement can invalidate the submission. Both the applicant and the endorsing physician or psychologist must provide their signatures.
Incorrect Endorsement: The physician or psychologist must check all applicable boxes in the endorsement section. Omitting any necessary checks may result in the application being deemed incomplete.
Failure to Use the Correct Form: Submitting a different version of the admission form, rather than the one specifically required by the Behavioral Health Administration, can cause the application to be rejected.
Neglecting to Provide Contact Information: Not including a phone number for the applicant or the endorsing physician can hinder communication and the processing of the application.
Ignoring Legal Requirements: Not understanding or adhering to the legal provisions outlined in the Health-General Article, §10-609 may lead to complications or denial of admission.
The Maryland Admission form is a crucial document for individuals seeking voluntary admission to a mental health facility in Maryland. Alongside this form, several other documents and forms are often required to ensure a comprehensive understanding of the individual's needs and legal rights. Below is a list of these additional forms and documents that may be necessary during the admission process.
Each of these documents plays a vital role in the admission process, ensuring that individuals receive appropriate care while also protecting their rights. It is essential for applicants and their families to understand these forms and their purposes as they navigate the mental health system in Maryland.
The Maryland Admission form shares similarities with the Patient Consent Form used in healthcare settings. Both documents require the individual to provide personal information and demonstrate an understanding of their rights regarding treatment. The Patient Consent Form also serves as a legal agreement, ensuring that the patient is aware of the nature of the treatment they are agreeing to, similar to how the Maryland Admission form outlines the need for the applicant to understand their mental health treatment. Both forms aim to protect the rights of individuals while ensuring that they are informed participants in their care.
Another document akin to the Maryland Admission form is the Informed Consent for Mental Health Treatment. This document outlines the treatment process and the potential risks involved. Like the Maryland Admission form, it emphasizes the individual's capacity to provide informed consent. Both documents require a signature from a licensed professional, affirming that the individual has been evaluated and deemed capable of understanding the treatment process. This ensures that individuals are making informed decisions about their mental health care.
The Psychiatric Evaluation Form is another similar document. It is used to assess an individual's mental health status before treatment begins. Much like the Maryland Admission form, it requires input from a licensed professional who evaluates the individual’s mental disorder and their ability to consent to treatment. Both forms play a crucial role in establishing a foundation for appropriate care and ensuring that the individual is ready for the treatment process.
Lastly, the Release of Information Form is comparable to the Maryland Admission form in that it involves consent from the individual regarding their personal information. This form allows healthcare providers to share pertinent information with other professionals involved in the individual's care. Both documents require the individual to understand the implications of their consent and are essential for facilitating communication within the healthcare system. This ensures that individuals receive comprehensive and coordinated care while maintaining their privacy rights.
When filling out the Maryland Admission form, it's important to approach the process with care. Here’s a handy list of things to do and avoid to ensure a smooth application experience.
Following these guidelines will help ensure that your application is complete and accurate, setting the stage for a smoother admission process. Good luck!
Misconceptions about the Maryland Admission form can lead to confusion and anxiety for individuals seeking treatment. Here are ten common misconceptions clarified:
Understanding these misconceptions can help individuals navigate the admission process with greater confidence and clarity.
When filling out and using the Maryland Admission form, consider the following key takeaways: