The Maryland Admission Form is a crucial document used for individuals seeking voluntary admission to a mental health facility. This application allows a person, aged 16 or older, to request care or treatment for a mental disorder, ensuring that their rights and understanding are respected throughout the process. To begin the admission process, please fill out the form by clicking the button below.
The Maryland Admission form serves as a crucial document for individuals seeking voluntary admission to mental health facilities within the state. This application is structured to ensure that potential patients can clearly express their desire for treatment, while also providing essential personal information such as their name, address, and date of birth. Importantly, the form requires the endorsement of a licensed physician or psychologist, who must confirm the presence of a mental disorder and the individual's capacity to understand and consent to their treatment. This dual requirement not only safeguards the rights of the applicant but also ensures that the treatment provided is appropriate and necessary. Additionally, the form outlines the legal framework under which voluntary admissions are processed, emphasizing the individual's right to request release from the facility after a specified period. Furthermore, the document underscores the commitment to non-discrimination in the provision of services, aligning with federal civil rights protections. In essence, the Maryland Admission form is designed to facilitate a respectful and informed approach to mental health care, prioritizing the needs and rights of individuals seeking help.
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State of Maryland – Department of Health and Mental Hygiene
BEHAVIORAL HEALTH ADMINISTRATION
Catonsville, MD 21228
APPLICATION FOR VOLUNTARY ADMISSION
To the Administrative Head of:
Name of Facility
I hereby apply for voluntary admission to your facility for the care or treatment of a mental disorder pursuant to the provisions of Health-General Article, §10-609, Annotated Code of Maryland, which has been explained and provided to me (See law printed on reverse of this form.)
_________________________________________________
_____________________________________________
Printed Name of Applicant
Signature of Applicant
Address
Date of Birth
__________________________________________________
Telephone Number
Date
Time
PHYSICIAN’S OR PSYCHOLOGIST’S ENDORSEMENT
I have examined
, and I find that:
The individual has a mental disorder;
The mental disorder is susceptible to care or treatment;
The individual understands the nature of the request for treatment;
The individual is able to give continuous assent to retention by the facility; and
The individual is able to ask for release.
I certify that I am duly licensed to practice medicine in the State of Maryland, pursuant to the Health Occupations Article, §14-305, Annotated Code of Maryland.
I certify that I am licensed under the Health Occupations Article, Title 18, Annotated Code of Maryland, to practice psychology in the State of Maryland.
Printed Name of Physician or Psychologist
Signature of Physician or Psychologist
Phone Number
The services and programs of the Department of Health and Mental Hygiene are provided on a non-discriminatory basis and in compliance with Article VI of the Civil Rights Act of 1964. Any complaints regarding alleged discrimination may be filed in writing with the Director, Behavioral Health Administration, Spring Grove Hospital Center, 55 Wade Avenue, Dix Building, Catonsville, MD 21228 and the Office of Civil Rights, U.S. Department of Health and Human Services, 150 S. Independence Mall West, Suite 372, Philadelphia, PA 19106-3499.
Application for Voluntary Admission must be on this form [Health-General Article, §10-609(b)(1)]
DHMH #4 (Revised September 2, 2014)
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HEALTH-GENERAL ARTICLE
§10-609. Application by individual
(a)In general. — Application for voluntary admission of an individual to a facility may be made under this section by the individual, if the individual is 16 years old or older.
(b)Application. — The applicant shall:
(1)Submit a formal, written application that contains the personal information and is on the form required by the Administration; or
(2)Informally request admission.
(c)Admission limitations — In general. — A facility may not admit an individual under this section unless:
(1)The individual has a mental disorder;
(2)The mental disorder is susceptible to care or treatment;
(3)The individual understands the nature of the request for admission;
(4)The individual is able to give continuous assent to retention by the facility; and
(5)The individual is able to ask for release.
(d)Admission limitations — Individuals 65 or older. — (1) In addition to the limitations in subsection (c) of this section, a State facility may not admit an individual who is 65 years old or older unless a geriatric evaluation team determines that there is no available, less restrictive form of care or treatment that is adequate for the needs of the individual.
(2)If admission is denied because of the determination of the geriatric evaluation team, the team shall;
(i)Inform the individual; and
(ii)Help the individual obtain the less restrictive form of care or treatment that the geriatric evaluation team finds would be adequate for the needs of the individual.
§10-803. Voluntary admissions.
(a)Informal request. — An individual who is admitted voluntarily to a facility, on an informal request, may leave the facility at any time between 9 a.m. and 4 p.m., unless the admission status of the individual has been changed to an involuntary admission.
(b)Formal applications — An individual who has been admitted voluntarily, under a formal written application, may not be held for more than 3 days after the individual asks for release, unless the admission status of the individual has been changed to an involuntary admission.
(c)Formal applications — Minors. — A minor who has been admitted voluntarily, on the application of a parent or guardian of the minor, may not be held for more than 3 days after the applicant for the admission asks for release, unless the admission status of the minor has been changed to an involuntary admission.
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Misconception 1: The Maryland Admission form is only for individuals over 18 years old.
This is incorrect. Individuals who are 16 years old or older can apply for voluntary admission using this form. It is important for younger individuals to know they have this option available to them.
Misconception 2: Completing the form guarantees admission to a facility.
Submitting the form does not guarantee admission. The facility must evaluate the individual to ensure they meet specific criteria, including having a mental disorder that is treatable.
Misconception 3: Once admitted, individuals cannot leave the facility.
This is not true. Individuals who are admitted voluntarily can request to leave at any time during specified hours, unless their status has changed to involuntary admission.
Misconception 4: A physician's endorsement is not necessary for admission.
Actually, a physician or psychologist must endorse the application. Their endorsement confirms the individual's mental health status and ability to understand the treatment request.
Misconception 5: The form does not protect against discrimination.
On the contrary, the services provided under this form comply with non-discrimination laws. Individuals can file complaints if they believe they have faced discrimination during the admission process.
Completing the Maryland Admission form for voluntary admission to a mental health facility is a critical step for individuals seeking care. However, several common mistakes can hinder the application process. Awareness of these pitfalls can facilitate a smoother admission experience.
One frequent error occurs when applicants fail to provide complete personal information. Incomplete sections, such as the applicant's name, address, or date of birth, can lead to delays. Each piece of information is essential for the facility to process the application efficiently. Ensuring that all fields are filled out accurately is vital.
Another common mistake is neglecting to secure the necessary endorsements from a physician or psychologist. The form requires a licensed professional to confirm the applicant's mental disorder and their capacity to understand the request for treatment. Without this endorsement, the application may be deemed invalid. Applicants should ensure that this section is thoroughly completed before submission.
Additionally, some individuals overlook the requirement for continuous assent. The form stipulates that the applicant must be able to give ongoing consent for their retention in the facility. Failing to acknowledge this aspect can result in complications during the admission process. It is important for applicants to understand their rights and the implications of their admission.
Misunderstanding the age-related provisions can also lead to errors. For applicants aged 65 and older, a geriatric evaluation team must assess their needs before admission. If this step is not followed, the application may be rejected. Individuals should be aware of these additional requirements to avoid unnecessary setbacks.
Moreover, some applicants mistakenly believe that submitting an informal request suffices for admission. While informal requests are permissible, a formal application is necessary for those wishing to ensure their admission under specific terms. Understanding the difference between these two processes is crucial for a successful application.
Lastly, overlooking the importance of the signature can derail the entire application. The form requires both the applicant’s and the endorsing physician's signatures. Without these, the application cannot proceed. Double-checking for signatures before submission can prevent this common oversight.
By being mindful of these common mistakes, individuals can enhance their chances of a successful admission to a mental health facility in Maryland. Attention to detail, understanding the requirements, and ensuring proper endorsements are key components of the application process.
Filling out the Maryland Admission form is a critical step for individuals seeking voluntary admission to a mental health facility. Here are some key takeaways to keep in mind:
By keeping these points in mind, you can navigate the Maryland Admission form with greater confidence and clarity.
When applying for voluntary admission to a facility in Maryland, several other forms and documents may accompany the Maryland Admission form. These documents ensure that the admission process is thorough and that all necessary information is collected. Here are some commonly used forms:
In summary, these additional forms play a vital role in the voluntary admission process, ensuring that all aspects of care, rights, and responsibilities are clearly understood and documented. Being well-prepared with these documents can help facilitate a smoother admission experience.
The Maryland Admission form shares similarities with the Patient Consent Form commonly used in healthcare settings. Both documents require the individual to provide personal information, including their name and contact details. The Patient Consent Form also seeks to ensure that the patient understands the nature of the treatment being proposed, much like the Maryland Admission form emphasizes the applicant's understanding of their mental health treatment. This shared focus on informed consent underscores the importance of the individual's awareness and agreement to the care they will receive.
Another document that resembles the Maryland Admission form is the Mental Health Treatment Plan. This plan outlines the specific goals and interventions for a patient undergoing mental health treatment. Similar to the admission form, the treatment plan requires input from both the patient and the healthcare provider, ensuring that the patient’s needs and preferences are taken into account. Both documents aim to facilitate a collaborative approach to care, promoting a partnership between the individual and their treatment team.
The Informed Consent for Psychotherapy is another document that mirrors the Maryland Admission form in its purpose and structure. This consent form outlines the nature of the therapeutic relationship, potential risks, and the rights of the client. Like the admission form, it requires the client to acknowledge their understanding and agreement to participate in treatment. This emphasis on informed consent is crucial in establishing trust and transparency between the therapist and the client.
Similarly, the Release of Information form is akin to the Maryland Admission form in that it requires the individual's consent before sharing personal health information. This document ensures that the individual understands what information will be shared, with whom, and for what purpose. Both forms prioritize the individual's autonomy and right to make informed decisions regarding their mental health care.
Lastly, the Behavioral Health Assessment form shares common ground with the Maryland Admission form. This assessment collects detailed information about the individual's mental health history, current symptoms, and treatment needs. Like the admission form, it is designed to gather essential information that will guide the treatment process. Both documents are integral to ensuring that the individual receives appropriate and effective care tailored to their specific circumstances.