Form MC-105 "Notice of Emergency Detention and Application for Evaluation" - Alaska

What Is Form MC-105?

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

Form Details:

  • Released on November 1, 2019;
  • The latest edition provided by the Alaska Court System;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form MC-105 by clicking the link below or browse more documents and templates provided by the Alaska Court System.

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Download Form MC-105 "Notice of Emergency Detention and Application for Evaluation" - Alaska

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NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
(AS 47.30.705)
Instructions
AS 47.30.705 authorizes custody for emergency evaluation when considerations of safety
do not allow initiation of involuntary commitment procedures.
Peace Officers: This form must be completed when you take a person into emergency
protective custody under AS 47.30.705. Give the completed form to the health care
professional when you deliver the person to the health care facility.
Psychiatrists, Physicians, Psychologists: This form must be completed when a person is
brought to a health care facility by someone other than a peace officer, and the person is
detained for examination and evaluation.
Petition for Order Authorizing Hospitalization for
 If this form is completed and a
Evaluation (form MC-100)
is later filed with the court, this form must be attached to
Petition
the
.
ALL FOUR SECTIONS BELOW MUST BE COMPLETELY FILLED OUT.
I. PERSON IN CUSTODY
Name:
First
Middle
Last
Date of Birth:
Gender:
Race:
Married:
yes
no
Respondent is a minor. Parents/guardian contact information is as follows:
Name(s):
Address:
Phone:
II. LOCATION OF PERSON IN CUSTODY
Taken into emergency custody on (date)
at (time)
am
pm.
Taken into custody by:
Peace Officer
Ambulance
Other person (name and relationship to patient)
Delivered to (facility)
on (date)
at (time)
am
pm.
Page 1 of 2
MC-105 (11/19)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
AS 47.30.705
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
(AS 47.30.705)
Instructions
AS 47.30.705 authorizes custody for emergency evaluation when considerations of safety
do not allow initiation of involuntary commitment procedures.
Peace Officers: This form must be completed when you take a person into emergency
protective custody under AS 47.30.705. Give the completed form to the health care
professional when you deliver the person to the health care facility.
Psychiatrists, Physicians, Psychologists: This form must be completed when a person is
brought to a health care facility by someone other than a peace officer, and the person is
detained for examination and evaluation.
Petition for Order Authorizing Hospitalization for
 If this form is completed and a
Evaluation (form MC-100)
is later filed with the court, this form must be attached to
Petition
the
.
ALL FOUR SECTIONS BELOW MUST BE COMPLETELY FILLED OUT.
I. PERSON IN CUSTODY
Name:
First
Middle
Last
Date of Birth:
Gender:
Race:
Married:
yes
no
Respondent is a minor. Parents/guardian contact information is as follows:
Name(s):
Address:
Phone:
II. LOCATION OF PERSON IN CUSTODY
Taken into emergency custody on (date)
at (time)
am
pm.
Taken into custody by:
Peace Officer
Ambulance
Other person (name and relationship to patient)
Delivered to (facility)
on (date)
at (time)
am
pm.
Page 1 of 2
MC-105 (11/19)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
AS 47.30.705
III. PROBABLE CAUSE
I certify that probable cause exists under AS 47.30.705 to believe that the above-named person
is mentally ill and as a result of that condition is:
Gravely disabled
Likely to cause serious harm to self
Likely to cause serious harm to others
of such an immediate nature that considerations of safety do not allow initiation of involuntary
commitment procedures under AS 47.30.700.
Information Supporting Probable Cause:
IV. PERSON MAKING THIS APPLICATION
I certify that I am a:
Peace Officer
Psychiatrist licensed to practice in Alaska or employed by the federal government
Physician licensed to practice in Alaska or employed by the federal government
Clinical psychologist licensed by the state Board of Psychologist and Psychological
Associate Examiners
Date and Time
Signature of Person Making this Application
Print or Type Name
Daytime Telephone Number(s)
Mailing Address
City
State
Zip
AS 47.30.705 provides:
Emergency detention for evaluation. (a) A peace officer, a psychiatrist or
physician who is licensed to practice in this state or employed by the federal government, or a clinical
psychologist licensed by the state Board of Psychologist and Psychological Associate Examiners who has
probable cause to believe that a person is gravely disabled or is suffering from mental illness and is likely
to cause serious harm to self or others of such immediate nature that considerations of safety do not
allow initiation of involuntary commitment procedures set out in AS 47.30.700, may cause the person to
be taken into custody and delivered to the nearest evaluation facility. A person taken into custody for
emergency evaluation may not be placed in a jail or other correctional facility except for protective
custody purposes and only while awaiting transportation to a treatment facility. However, emergency
protective custody under this section may not include placement of a minor in a jail or secure facility. The
peace officer or mental health professional shall complete an application for examination of the person in
custody and be interviewed by a mental health professional at the facility.
Page 2 of 2
MC-105 (11/19)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
AS 47.30.705
Page of 2