Welfare and Institutions Code section 5262

A second notice of certification for imminently suicidal persons is required for all involuntary 14-day intensive treatment, pursuant to this article, and shall be in substantially the following form:

To the Superior Court of the State of California for the County of ______

The authorized agency providing 14-day intensive treatment, County of _________, has custody of: _________

Name____________

Address____________

Age____________

Sex____________

Marital status____________

Religious affiliation____________

The undersigned allege that the above-named person presents an imminent threat of taking his own life.This allegation is based upon the following facts:

This allegation is supported by the accompanying affidavits signed by____________.

The above-named person has been informed of this allegation and has been advised of, but has not been able or willing to accept referral to, the following services:

We, therefore, certify the above-named person to receive additional intensive treatment for no more than 14 days beginning this day of (Month), 19__, in the intensive treatment facility herein named________.

We hereby state that a copy of this notice has been delivered this day to the above-named person and that he has been clearly advised of his continuing legal right to a judicial review by habeas corpus, and this term has been explained to him.

(Date)

Signed

Countersigned Representing intensive treatment facility