Requirements of Certificate

The certificate shall be in writing, executed under oath, and shall include the following information:

(a)the name and address, if known, of the respondent;

(b)the name and address, if known, of the respondent’s spouse, legal counsel, conservator or guardian, and next-of-kin;

(c)the name and address, if known, of anyone currently providing psychiatric care to the respondent; COL622016 CH. 82A ASSISTED OUTPATIENT TREATMENT

(d)the names and addresses, if known, of other persons with knowledge of the respondent’s mental illness who may be called as witnesses at the assisted treatment hearing;

(e)the name and work address of the certifying psychiatrist or other physician;

(f)the name and address of the facility in which the respondent is undergoing emergency treatment/observation;

(g)the certifying psychiatrist or other physician’s statement that he or she has examined the respondent since the respondent was placed in emergency treatment/observation; and

(h)the certifying psychiatrist or other physician’s statement that, in his or her clinical opinion, the respondent is a danger to himself, herself or to others, or gravely disabled, and the clinical basis for this opinion.