DA Form 4359 Authorization for Psychiatric Service Treatment

DA Form 4359 or the "Authorization For Psychiatric Service Treatment" is a Department of the Army-issued form used by and within the United States Military.

The form - often incorrectly referred to as the DD form 4359 - was last revised on February 1, 2003. Download an up-to-date fillable DA Form 4359 down below in PDF-format or look it up on the Army Publishing Directorate website.

ADVERTISEMENT
AUTHORIZATION FOR PSYCHIATRIC SERVICE TREATMENT
For use of this form see AR 40-66; the proponent agency is the Office of The Surgeon General.
STATEMENT OF AUTHORIZATION
1. I hereby request and consent to hospitalization in a treatment unit of the Psychiatry Service. I understand that
this admission is required for adequate study and treatment of my case. I understand that I may be asked to
remain on the ward or in the company of staff members at all times.
2. The policies of this treatment unit have been explained to me. I acknowledge that no guarantee or assurance
has been made as to the results that may be obtained.
3. I understand that my hospitalization is not a commitment and upon my written or verbal request for discharge,
action will be initiated immediately to effect my discharge in accord with local and Federal laws and statutes.
4. I understand that photographs, including videotapes and moving pictures, may be taken while under treatment
and that they may be viewed by various personnel undergoing training or indoctrination at this or other facilities. I
also understand that medical students and other professional trainees may be present as observers in accordance
with ordinary practices of this medical facility. I consent to the taking of such pictures and to observation by
authorized personnel, subject to the following conditions:
a. Neither my name nor the names of my family will be used to identify said pictures.
b. Said pictures and any information gained from observation will be used only for purposes of medical study
or research.
AUTHORIZING SIGNATURES
Patient (or authorized person if other than patient)
Date (YYYYMMDD)
Admitting physician or his specifically designated representative
Date (YYYYMMDD)
Witness (Spouse or other appropriate relative should witness
Date (YYYYMMDD)
signature whenever possible)
PATIENT'S IDENTIFICATION (Mechanically Imprint, Type or Print)
Patient's Name - last, first, middle initial;
Sex; Year of Birth; Relationship to Sponsor;
Component/Status; Department/Service.
Sponsors Name - last, first, middle initial;
Rank/Grade; SSN or Identification Number;
Organization.
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.01ES
DA FORM 4359, FEB 2003
AUTHORIZATION FOR PSYCHIATRIC SERVICE TREATMENT
For use of this form see AR 40-66; the proponent agency is the Office of The Surgeon General.
STATEMENT OF AUTHORIZATION
1. I hereby request and consent to hospitalization in a treatment unit of the Psychiatry Service. I understand that
this admission is required for adequate study and treatment of my case. I understand that I may be asked to
remain on the ward or in the company of staff members at all times.
2. The policies of this treatment unit have been explained to me. I acknowledge that no guarantee or assurance
has been made as to the results that may be obtained.
3. I understand that my hospitalization is not a commitment and upon my written or verbal request for discharge,
action will be initiated immediately to effect my discharge in accord with local and Federal laws and statutes.
4. I understand that photographs, including videotapes and moving pictures, may be taken while under treatment
and that they may be viewed by various personnel undergoing training or indoctrination at this or other facilities. I
also understand that medical students and other professional trainees may be present as observers in accordance
with ordinary practices of this medical facility. I consent to the taking of such pictures and to observation by
authorized personnel, subject to the following conditions:
a. Neither my name nor the names of my family will be used to identify said pictures.
b. Said pictures and any information gained from observation will be used only for purposes of medical study
or research.
AUTHORIZING SIGNATURES
Patient (or authorized person if other than patient)
Date (YYYYMMDD)
Admitting physician or his specifically designated representative
Date (YYYYMMDD)
Witness (Spouse or other appropriate relative should witness
Date (YYYYMMDD)
signature whenever possible)
PATIENT'S IDENTIFICATION (Mechanically Imprint, Type or Print)
Patient's Name - last, first, middle initial;
Sex; Year of Birth; Relationship to Sponsor;
Component/Status; Department/Service.
Sponsors Name - last, first, middle initial;
Rank/Grade; SSN or Identification Number;
Organization.
PREVIOUS EDITIONS ARE OBSOLETE.
APD LC v1.01ES
DA FORM 4359, FEB 2003

Download DA Form 4359 Authorization for Psychiatric Service Treatment

1006 times
Rate
4.5(4.5 / 5) 245 votes
ADVERTISEMENT