Form AOC-703A "Certification of Qualified Health Professional (Involuntary Treatment-Substance Use Disorder)" - Kentucky

What Is Form AOC-703A?

This is a legal form that was released by the Kentucky Court of Justice - a government authority operating within Kentucky. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2019;
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Download Form AOC-703A "Certification of Qualified Health Professional (Involuntary Treatment-Substance Use Disorder)" - Kentucky

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AOC-703A
Doc. Code: CIT
Case No. ____________________
Rev. 6-19
Page 1 of 3
l e x
Court ________________________
District
e t
j u s t i t i a
Commonwealth of Kentucky
County ______________________
Court of Justice
www.courts.ky.gov
Certification of Qualified
Health Professional
Division ______________________
KRS 222.005; 222.431; 222.433
(Involuntary Treatment-Substance Use Disorder)
IN THE INTEREST OF:
RESPONDENT_____________________________________________________
1. Comes the Affiant, ____________________________________________, and states that he/she is a Qualified Health
Professional as defined in KRS Chapter 222, and he/she is,
q A Qualified Mental Health Professional as defined in KRS 202A.011; and/or
q An Alcohol and Drug Counselor certified under KRS Chapter 309; and/or
q A Physician, licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the
government of the United States while engaged in the performance of official duties.
2. Affiant further states that he/she examined the above-named Respondent and based on that examination, in his/her
professional opinion, the Respondent
A. q does q does not suffer from a substance use disorder; and
B. q does q does not present an imminent threat of danger to self, family or others as a result of a substance
use disorder; or there
q does q does not exist a substantial likelihood of such a threat in the near future; and
C. q can
q cannot reasonably benefit from treatment.
3. The facts that support Affiant's belief that Respondent does suffer from a substance use disorder:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. The facts that support Affiant's belief that Respondent presents an imminent threat of danger to self, family or others as a
result of a substance use disorder or that there exists a substantial likelihood of such a threat in the near future:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Diagnostic impressions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
AOC-703A
Doc. Code: CIT
Case No. ____________________
Rev. 6-19
Page 1 of 3
l e x
Court ________________________
District
e t
j u s t i t i a
Commonwealth of Kentucky
County ______________________
Court of Justice
www.courts.ky.gov
Certification of Qualified
Health Professional
Division ______________________
KRS 222.005; 222.431; 222.433
(Involuntary Treatment-Substance Use Disorder)
IN THE INTEREST OF:
RESPONDENT_____________________________________________________
1. Comes the Affiant, ____________________________________________, and states that he/she is a Qualified Health
Professional as defined in KRS Chapter 222, and he/she is,
q A Qualified Mental Health Professional as defined in KRS 202A.011; and/or
q An Alcohol and Drug Counselor certified under KRS Chapter 309; and/or
q A Physician, licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the
government of the United States while engaged in the performance of official duties.
2. Affiant further states that he/she examined the above-named Respondent and based on that examination, in his/her
professional opinion, the Respondent
A. q does q does not suffer from a substance use disorder; and
B. q does q does not present an imminent threat of danger to self, family or others as a result of a substance
use disorder; or there
q does q does not exist a substantial likelihood of such a threat in the near future; and
C. q can
q cannot reasonably benefit from treatment.
3. The facts that support Affiant's belief that Respondent does suffer from a substance use disorder:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
4. The facts that support Affiant's belief that Respondent presents an imminent threat of danger to self, family or others as a
result of a substance use disorder or that there exists a substantial likelihood of such a threat in the near future:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
5. Diagnostic impressions:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
AOC-703A
Rev. 6-19
Page 2 of 3
6. Other factors contributing to need for treatment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
7. Goal of treatment and recommendation for treatment:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
8. Date examination was performed: ______________________________, 2_____
Further, Affiant sayeth naught.
_____________________________, 2_____
____________________________________________
Date
Signature of QHP
____________________________________________
Name of QHP (please print)
____________________________________________
Title of QHP (please print)
____________________________________________
Name of Treatment Facility of QHP (please print)
Subscribed and sworn to before me this ________ day of __________________________, 2______
My Commission Expires: _________________________
____________________________________________
Notary Public
____________________________________________
County, Kentucky
NOTE: The Respondent shall be examined no later than twenty-four (24) hours before the hearing date by two (2) Qualified Health
Professionals, at least one (1) of whom is a physician. A separate Certification of Qualified Health Professional (AOC-703A) must
be filed with the Court by each of the two (2) Qualified Heath Professionals named in the Hearing, Examination and Appointment
of Counsel Notice and Order (AOC-701A). The Qualified Health Professionals shall certify their findings to the Court within twenty-
four (24) hours of the examination. See page 3 for more information on Qualified Health Professionals.
Petitioner is responsible for all costs of the examination.
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AOC-703A
Rev. 6-19
CERTIFICATION
Page 3 of 3
Note: If for 72-hour involuntary treatment, Certification is to be completed and filed by ONE "Qualified Health Professional."
If for 60/360 day involuntary treatment, Certification is to be completed and filed by each of TWO "Qualified Health
Professionals," one of whom must be a licensed physician.
Criteria for each professional are listed below
"Qualified health professional" has the same meaning as qualified mental health professional in KRS 202A.011, except that it also
includes an alcohol and drug counselor certified under KRS Chapter 309.
“Qualified mental health professional” under KRS 202A.011(12) means:
a.
A physician licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the
government of the United States while engaged in the performance of official duties.
A psychiatrist licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the
b.
government of the United States while engaged in the practice of official duties, who is certified or eligible to apply
for certification by the American Board of Psychiatry and Neurology, Inc.
A psychologist with the health service provider designation, a psychological practitioner, a certified psychologist,
c.
or a psychological associate, licensed under the provisions of KRS Chapter 319.
A licensed registered nurse with a master’s degree in psychiatric nursing from an accredited institution and two
d.
(2) years of clinical experience with mentally ill persons; or a licensed registered nurse, with a bachelor’s degree
in nursing from an accredited institution, who is certified as a psychiatric and mental health nurse by the American
Nurses Association and who has three (3) years of inpatient or outpatient clinical experience in psychiatric nursing
and is currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric
unit of a general hospital or a private agency or company engaged in provision of mental health services or a regional
community program for mental health and individuals with an intellectual disability.
e.
A licensed clinical social worker licensed under the provisions of KRS 335.100, or a certified social worker licensed
under the provisions of KRS 335.080 with three (3) years of inpatient or outpatient clinical experience in psychiatric
social work and currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or
a psychiatric unit of a general hospital or a private agency or company engaged in the provision of mental health
services or a regional community program for mental health and individuals with an intellectual disability.
f.
A marriage and family therapist licensed under the provisions of KRS 335.300 to 335.399 with three (3) years
of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a
hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency
or company engaged in providing mental health services, or a regional community program for mental health and
individuals with an intellectual disability.
A professional counselor credentialed under the provisions of KRS Chapter 335.500 to 335.599 with three (3)
g.
years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a
hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency
or company engaged in providing mental health services, or a regional community program for mental health and
individuals with an intellectual disability.
A physician assistant licensed under KRS 311.840 to 311.862, who meets one (1) of the following requirements:
h.
1. Provides documentation that he or she has completed a psychiatric residency program for physician assistants;
2. Has completed at least one thousand (1,000) hours of clinical experience under a supervising physician, as defined by KRS 311.840,
who is a psychiatrist and is certified or eligible for certification by the American Board of Psychiatry and Neurology, Inc.;
3. Holds a master's degree from a physician assistant program accredited by the Accreditation Review Commission on Education for the
Physician Assistant or its predecessor or successor agencies, is practicing under a supervising physician as defined by KRS 311.840,
and:
a. Has two (2) years of clinical experience in the assessment, evaluation, and treatment of mental disorders; or
b. Has been employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general
hospital or a private agency or company engaged in the provision of mental health services or a regional community program for
mental health and individuals with an intellectual disability for at least two (2) years; or
4. Holds a bachelor's degree, possesses a current physician assistant certificate issued by the board prior to July 15, 2002, is practicing
under a supervising physician as defined by KRS 311.840, and:
a. Has three (3) years of clinical experience in the assessment, evaluation, and treatment of mental disorders; or
b. Has been employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general
hospital or a private agency or company engaged in the provision of mental health services or a regional community program for
mental health and individuals with an intellectual disability for at least three (3) years.
“Certified Alcohol and Drug Counselor” under KRS 309.080 means a person certified by the Kentucky Board of Alcohol and Drug
Counselors pursuant to KRS 309.080 to 309.089.
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