EXHIBIT C

APPLICATION FOR EMERGENCY ADMISSION FOR EVALUATION

(Pursuant to A.R.S. § 36-524)

STATE OF ARIZONA                                  )

) ss

COUNTY OF ______________________)

__________________________________)

The undersigned applicant, being first duly sworn/affirmed, hereby requests that ______________________________________________

(Evaluation Agency)

admit the person named herein for evaluation.

1.      The undersigned applicant alleges that there is now in the County a person whose name and address are:

(Name)                                                                                                     (Address)

and that s/he believes that the person has a mental disorder and, as a result of said mental disorder, is: A danger to self;                  A danger to others;

and that, during the time necessary to complete pre-petition screening under A.R.S. §§ 36-520 and 36-521, the person is likely without

immediate hospitalization to suffer serious physical harm or serious illness or is likely to inflict serious physical harm upon another person.

The conclusion that the person has a mental disorder is based on the following facts: __________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________ The specific nature of the danger posed by this person is: ________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________ A summary of the personal observations upon which this statement is based is as follows: ______________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

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PERSONAL DATA OF PROPOSED PATIENT:

Age ________________________   Date of Birth ________________________ Sex _______________ Race _________________ Weight _________________________       Height __________________ Hair Color ___________ Eye Color___________________ Marital Status ____________________ Number of Children_______________________________

Social Security No. ________________________________ Religion _________________________________________________ Distinguishing Marks ____________________________________________________________________________ Occupation ____________________________________________________________________________________ Present Location________________________________________________________________________________ Dates and Places of Previous Hospitalization _________________________________________________________

How Long in Arizona _____________ State Last From___________________________________

Veteran? ___________________ C-No. _______________________ Education__________________________________________

NAME, ADDRESS AND TELEPHONE NUMBER OF:

1)     Guardian         __________________________________________________________________________________________________

2)     Spouse____________________________________________________________________________________________________

3)       Next of Kin

_______________________________________________________________________________________________

4)       Significant Other Persons

____________________________________________________________________________________

_________________________________________________________________________________________________________

___________________________________                          __________________________________________________________ DATE                                                                                      SIGNATURE OF APPLICANT

Printed or Typed Name of Applicant ________________________________________________________________________________ Relationship to Proposed Patient ___________________________________________________________________________________ Applicant’s Address _____________________________________________________________________________________________ Applicant’s Telephone ___________________________________________________________________________________________ SUBSCRIBED AND SWORN to before me this __________ day of ______________________________, 19______.

My Commission Expires:

___________________________________________________ Notary Public

__________________________________

ADHS/BHS Form MH-104 (9/93)

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit C repealed, new Exhibit C adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3).

Renumbered from a position after R9-21-503 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).