Emergency Form

Emergency Order of Detention (EOD)

Application for emergency psychiatric detention for individuals who present an imminent risk of harm to themselves or others due to mental illness.

Download Printable Version Suicide Risk Assessment

Important Legal Notice

Emergency detention laws and procedures vary significantly by state and jurisdiction. This form is a general template and must be adapted to comply with your state's specific requirements.

• Texas: Emergency Detention (ED) + Order of Protective Custody (OPC) - 48 hour limit
• Oklahoma: EOD under 43A O.S. 5-208 - up to 120 hours (5 days)
• Indiana: Application for Emergency Detention - 14 day limit
• Consult your facility's legal counsel before use

APPLICATION FOR EMERGENCY ORDER OF DETENTION

Involuntary Psychiatric Hold - Mental Health Emergency

Section 1: Applicant Information

Applicant Name *

Title/Position

License Number (if applicable)

Phone Number

Facility Name

Facility Address

Section 2: Individual to be Detained

Full Legal Name *

Date of Birth

Gender

Address (if known)

SSN (Last 4 digits)

Section 3: Grounds for Emergency Detention

The above-named individual requires emergency detention because (check all that apply):

Danger to Self: The individual presents a substantial risk of imminent harm to themselves, including suicide or serious self-injury.Danger to Others: The individual presents a substantial risk of imminent harm to others.Gravely Disabled: The individual is unable to provide for basic physical needs (food, clothing, shelter) due to mental illness.

Evidence of Mental Illness *

Basis for Determination of Imminent Danger *

Behavioral Observations

Less Restrictive Alternatives Considered *

Section 4: Physician/Examiner Certification

Examining Physician/Clinician Name

License Number

Date of Examination

Time of Examination

I certify that I have personally examined the above-named individual and, based on my examination, I believe that:

The individual has a mental illness;
The individual presents a substantial risk of serious harm to self or others;
The risk of harm is imminent unless the individual is immediately restrained;
Emergency detention is the least restrictive means by which the individual can be restrained.

Signature:

Date:

Section 5: Application Filing

Date of Application

Time of Application

I, the undersigned applicant, swear or affirm that the statements contained in this application are true and correct to the best of my knowledge and belief.

Applicant Signature:

Date:

Documentation Requirements

Ensure thorough documentation of: (1) specific behaviors/statements indicating risk, (2) mental status examination findings, (3) why less restrictive alternatives are insufficient, (4) attempts to obtain voluntary admission if applicable.

State Resources

Indiana: Official State Form 52744

Texas: Texas Hospital Association Guide

Oklahoma: DRTC Involuntary Commitment Guide