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

Form MC-105 or the "Notice Of Emergency Detention And Application For Evaluation" is a form issued by the Alaska Court System.

Download a PDF version of the Form MC-105 down below or find it on the Alaska Court System Forms website.

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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.
 If this form is completed and a Petition for Order Authorizing Hospitalization for
Evaluation (form MC-100) is later filed with the court, this form must be attached to
the Petition.
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:
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:
Page 1 of 2
MC-105 (10/13)(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.
 If this form is completed and a Petition for Order Authorizing Hospitalization for
Evaluation (form MC-100) is later filed with the court, this form must be attached to
the Petition.
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:
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:
Page 1 of 2
MC-105 (10/13)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
AS 47.30.705
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.
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
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 (10/13)(cs)
NOTICE OF EMERGENCY DETENTION AND APPLICATION FOR EVALUATION
AS 47.30.705

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

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