Rule 12.36—Form 4: Physician or Mental Health Professional’s Report of Examination Instructions

Check this box if a qualified mental health professional assisted with this examination.

Check this box if no qualified mental health professional assisted with this examination.

Enter the full name of the qualified mental health professional who assisted with the examination. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the business or organization name for the assisting mental health professional. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the street address for the assisting mental health professional's business or practice location. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the city for the assisting mental health professional's business or practice address. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the state for the assisting mental health professional's business or practice address. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the ZIP code for the assisting mental health professional's business or practice address. Fill only if 'Qualified mental health professional assisted (Yes)' is 'Yes'.

Enter the month in which the examination took place.

Enter the day of the month on which the examination took place.

Enter the year in which the examination took place.

Enter the hour when the examination occurred.

Enter the minutes portion of the time when the examination occurred.

Check this box if the examination time entered occurred in the morning (a.m.).

Check this box if the examination time entered occurred in the afternoon or evening (p.m.).

Enter the primary email address for the physician or mental health professional.

Enter an additional email address for the physician or mental health professional, if applicable.

Check this box if this is an examination under Iowa Code section 229.10.

Check this box if this is not an examination under Iowa Code section 229.10.

Enter the name of the facility where the physician or mental health professional is associated for this report.

Enter the city for the facility's mailing address.

Enter the state for the facility's mailing address.

Enter the ZIP code for the facility's mailing address.

Enter the nearest relative's full name (first and last).

Enter the nearest relative's relationship to the respondent (e.g., spouse, parent, sibling).

Enter the nearest relative's street address.

Enter the city of the nearest relative's address.

Enter the state of the nearest relative's address.

Enter the ZIP code for the nearest relative's address.

Enter the area code for the physician or mental health professional's phone number.

Enter the remaining digits of the physician or mental health professional's phone number.

Enter the printed full name of the physician or mental health professional completing this report.

Enter the professional title/credentials of the physician or mental health professional (e.g., MD, DO, PhD, LCSW).

Enter the physician or mental health professional’s signature to certify the report.

Check this box if, in your judgment, the Respondent is unable to satisfy basic needs (nourishment, clothing, essential medical care, or shelter) such that physical injury, debilitation, or death is likely.

Check this box if, in your judgment, the Respondent is not unable to satisfy basic needs to the extent that physical injury, debilitation, or death is likely.

Describe the facts and observations supporting your opinion that the respondent is unable to satisfy needs for nourishment, clothing, essential medical care, or shelter such that physical injury, debilitation, or death is likely. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages providing the basis for your answer to Question 10.

Check this box if the respondent has a prior history of noncompliance with treatment that significantly contributed to the need for emergency hospitalization or resulted in/attempted serious physical injury to self or others.

Check this box if the respondent does not have a prior history of noncompliance with treatment that significantly contributed to the need for emergency hospitalization or resulted in/attempted serious physical injury to self or others.

Provide the explanation and supporting facts for whether the respondent has a prior history of noncompliance with treatment that contributed to emergency hospitalization or resulted in (or attempted) serious physical injury. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages to provide more information for Question 11.

Check this box if, in your judgment, the Respondent can be evaluated on an outpatient basis.

Check this box if, in your judgment, the Respondent cannot be evaluated on an outpatient basis.

Provide the basis and supporting facts explaining whether the respondent can be evaluated on an outpatient basis.

Check this box if you have attached additional pages to provide more information for Question 12.

Check this box if the Respondent can, without danger to self or others, be released to the custody of a relative or friend during the course of evaluation.

Check this box if the Respondent cannot, without danger to self or others, be released to the custody of a relative or friend during the course of evaluation.

Provide the facts and clinical basis supporting whether the respondent can be released to the custody of a relative or friend without danger to self or others during the course of evaluation.

Check this box if you have attached additional pages for Question 13.

Check this box if, in your judgment, full-time hospitalization is necessary for the respondent’s evaluation.

Check this box if, in your judgment, full-time hospitalization is not necessary for the respondent’s evaluation.

Check this box if the Respondent has a prior history of other physical or mental illness.

Check this box if the Respondent does not have a prior history of other physical or mental illness.

Describe any prior physical or mental illnesses the respondent has had, including relevant details as requested in Question 15. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages to provide more information for Question 15.

Check this box if the Respondent was medicated at the time of examination.

Check this box if the Respondent was not medicated at the time of examination.

Enter the name(s) of any medication the respondent had been given at the time of examination, including the dosage, the approximate date and time administered, and the probable effects on the respondent. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages with medication details for Question 16.

Check this box if, in your judgment, the Respondent is mentally ill.

Check this box if, in your judgment, the Respondent is not mentally ill.

Provide your determination of whether the respondent is mentally ill, including the diagnosis and supporting facts such as symptoms and overt acts. Fill only if 'Yes (Respondent mentally ill)' is 'Yes'.

Check this box if you have attached additional pages to provide more information for this report.

Check this box if, in your judgment, the Respondent is treatable and likely to benefit from treatment.

Check this box if, in your judgment, the Respondent is not treatable or is not likely to benefit from treatment.

Provide the recommendations for treatment and the basis/reasons supporting why the respondent is treatable and likely to benefit from treatment. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages with recommendations and/or the basis for your recommendations for Question 6.

Check this box if, in your judgment, the Respondent is capable of making responsible decisions regarding hospitalization or treatment.

Check this box if, in your judgment, the Respondent is not capable of making responsible decisions regarding hospitalization or treatment.

Provide the explanation and supporting facts for your judgment about whether the respondent is capable of making responsible decisions regarding hospitalization or treatment. Fill only if 'No' is 'Yes'.

Check this box if you have attached additional pages to provide more information for Question 7.

Check this box if, in your judgment, the Respondent is likely to physically injure self or others if allowed to remain at liberty without treatment.

Check this box if, in your judgment, the Respondent is not likely to physically injure self or others if allowed to remain at liberty without treatment.

Describe the recent overt acts by the respondent that lead you to conclude the respondent is likely to physically injure self or others if allowed to remain at liberty without treatment, including approximate dates and any other relevant facts. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages to provide more information for Question 8.

Check this box if, in your judgment, the Respondent is likely to inflict serious emotional injury on those unable to avoid contact if allowed to remain at liberty without treatment.

Check this box if, in your judgment, the Respondent is not likely to inflict serious emotional injury on those unable to avoid contact if allowed to remain at liberty without treatment.

Describe the recent overt acts by the respondent and other relevant facts that support your conclusion that the respondent is likely to inflict serious emotional injury on people unable to avoid contact if allowed to remain at liberty without treatment. Fill only if 'Yes' is 'Yes'.

Check this box if you have attached additional pages to provide more information for Question 9.

Enter the respondent’s current or most recent occupation or job title.

Enter the respondent’s current marital status (for example, single, married, divorced, separated, or widowed).

Enter the total number of the respondent’s children.

Enter the names of the respondent’s children.

Enter any additional children’s names that did not fit on the line above.

Enter the respondent’s street address (including apartment or unit number, if applicable).

Enter the city for the respondent’s address.

Enter the state for the respondent’s address.

Enter the ZIP code for the respondent’s address.

Enter the respondent’s full legal name (first, middle, last).

Enter the month of the respondent’s date of birth.

Enter the day of the month on which the respondent was born.

Enter the year the respondent was born.

Enter the respondent’s place of birth (e.g., city and state/country).

Enter the respondent’s sex.

Enter the respondent’s full legal name (first, middle, last) for the case caption.

Enter the name of the Iowa county where this report is filed.

Enter the court case number assigned to this matter.

Enter the month in which the physician or mental health professional signed the form.

Enter the day of the month on which the physician or mental health professional signed the form.

Enter the year in which the physician or mental health professional signed the form.