IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT

In the Matter of the Necessity	)

for the Hospitalization of:	)

)

,	)	Case No.

Respondent	)

Date of Birth:	)	SCREENING INVESTIGATION

[Estimate age if unknown]	)	REPORT

Background Information

1. Respondent’s contact information, if known:

Address/Location:

Phone:

2. Is Respondent a minor? Yes No

3. Name of Petitioner:

Relationship to Respondent

Agency [if applicable]

4. Name of Screening Investigator:

Notes for Screening Investigator

Petitioner alleges Respondent is mentally ill and either “present[s] a likelihood of serious harm to self or others” or is “gravely disabled.” Legal definitions of these terms are included on the last page of this form. You have been asked to do a “screening investigation,” which is defined in Alaska Statute 47.30.915 as:

The investigation and review of facts that have been alleged to warrant emergency examination or treatment, including interviews with the persons making the allegations, any other significant witnesses who can readily be contacted for interviews, and, if possible, the respondent, and an investigation and evaluation of the reliability and credibility of persons providing information or making allegations.

Relevant information may include:

Presenting mental health concerns and problems identified by Petitioner (What is the basis for Petitioner’s belief that Respondent is mentally ill? What behavior causes Petitioner to believe that Respondent is a danger to self? A danger to others? Gravely disabled?)

Nature of the relationship between Petitioner and Respondent

History and background to presenting problems

Whether Respondent has been in the past or is currently under the care of a mental health professional, and whether Respondent is prescribed medications and is currently taking them

Whether Respondent has previously been hospitalized because of mental illness-related concerns

Whether Respondent has any presenting medical concerns

Whether police have been contacted in regard to the current presenting problems

Whether alcohol or substance use may be involved

Whether other witnesses, including family members, substantiate Petitioner’s information

Whether Respondent has a guardian

Summary of Investigation

1.	The investigator interviewed the following people: [Check all that apply]

Petitioner. Date/time/location of interview:

Respondent. Date/time/location of interview:

Other witnesses: [List names]

A.	Date/time/location:

B.	Date/time/location:

C.	Date/time/location:

D.	Date/time/location:

2.	Summary of interview with Petitioner:

3.	Summary of interview(s) with other witnesses:

4.	I interviewed Respondent, and a summary of that interview is below.

I didn’t (or wasn’t able to) interview Respondent, for the reason(s) explained below.

Evaluation

1.	Evaluation of the persons providing information: [Please comment on the reliability and credibility of the statements made in your interviews.]

2.	Please provide your assessment of the allegations raised in the petition: [Include your	opinion or recommendation as to whether Respondent meets the criteria to be involuntarily	hospitalized for assessment, and whether less restrictive alternatives would be more	appropriate.]

3.	Other comments:

Definitions

AS 47.30.915 defines the following terms:

"Mental illness" means an organic, mental, or emotional impairment that has substantial adverse effects on an individual's ability to exercise conscious control of the individual's actions or ability to perceive reality or to reason or understand; mental retardation, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, although persons suffering from these conditions may also be suffering from mental illness.

"Gravely disabled" means a condition in which a person as a result of mental illness

(A) is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, or personal safety as to render serious accident, illness, or death highly probable if care by another is not taken; or

(B) is so incapacitated that the person is incapable of surviving safely in freedom.

“Likely to cause serious harm" means a person who

(A) poses a substantial risk of bodily harm to that person's self, as manifested by recent behavior causing, attempting, or threatening that harm;

(B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical abuse, or substantial property damage to another person; or

(C) manifests a current intent to carry out plans of serious harm to that person's self or another.