Crisis Services - Baker Act

Forms

The links on this page all require the use of the Adobe Reader which is free from the Adobe.com web site or Microsoft Word for which a viewer is available from the Microsoft Website if needed.

IMPORTANT: Mandatory Forms may NOT be altered.

Recommended forms are those which are not required by the department, but which have been determined to satisfy the specific requirements for which the form was developed. Alterations of recommended forms may jeopardize this status.

Baker Act Forms - Mandatory: (IMPORTANT: Mandatory Forms may NOT be altered.)

• CF - MH 3052a June 2016: Report of Law Enforcement Officer Initiating Involuntary Examination
• CF - MH 3052b June 2016: Certificate of Professional Initiating Involuntary Examination
• CF - MH 3084 Feb. 2005: Baker Act Service Eligibility
• CF - MH 3089 Feb. 2005: Transfer Evaluation (To a State Mental Health Treatment Facility)
• CF - MH 3100 Feb. 2005: Transportation to Receiving Facility
• CF - MH 3118 June 2016: Cover Sheet to Department of Children and Families
• CF - MH 3125 Feb. 2005: Application for Designation as a Receiving Facility

Baker Act Forms - Recommended: Recommended forms are those which are not required by the department, but which have been determined to satisfy the specific requirements for which the form was developed. Alterations of recommended forms may jeopardize this status.

• CF - MH 3001 Jan. 1998: Ex Parte Order for Involuntary Examination | Spanish 
• CF - MH 3002 Feb. 2005: Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination | Spanish
• CF - MH 3008 Feb. 2005: Order for Involuntary Inpatient Placement
• CF - MH 3021 Feb. 2005: Notice of Petition for Involuntary Placement
• CF - MH 3022 Feb. 2005: Application for Appointment of Independent Expert Examiner | Spanish
• CF - MH 3024 Feb. 2005: Notice of Petition for Continued Involuntary Inpatient Placement
• CF - MH 3031 Feb. 2005: Order for Continued Involuntary Inpatient Placement or for Release
• CF - MH 3032 Feb. 2005: Petition for Involuntary Inpatient Placement
• CF - MH 3033 Feb. 2005: Notification to Court of Withdrawal of Petition for Hearing on Involuntary Inpatient or Involuntary Outpatient Placement
• CF - MH 3035 Feb. 2005: Petition Requesting Authorization for Continued Involuntary Inpatient Placement
• CF - MH 3036 Feb. 2005: Notice of Right to Petition for Writ of Habeas Corpus or for Redress of Grievances | Spanish
• CF - MH 3038 Feb. 2005: Notice of Release or Discharge
• CF - MH 3040 Feb. 2005: Application for Voluntary Admission (Receiving Facility) | Spanish
• CF - MH 3042a Feb. 2005: General Authorization for Treatment Except Psychotropic Medications | Spanish
• CF - MH 3042b Feb. 2005: Specific Authorization for Psychotropic Medications | Spanish
• CF - MH 3043 Feb. 2005: Inventory of Personal Effects | Spanish
• CF - MH 3044 Feb. 2005: Authorization for Release of Information | Spanish
• CF - MH 3045 Feb. 2005: Notice of Person's Admission for Involuntary Examination
• CF - MH 3046 Feb. 2005: Application for and Notice of Transfer to Another Facility | Spanish
• CF - MH 3048 Feb. 2005: Confidentiality Agreement | Spanish
• CF - MH 3049 Feb. 2005: Restriction of Communication or Visitors | Spanish
• CF - MH 3051a Feb. 2005: Notice of Right of Person on Voluntary Status to Request Discharge From a Receiving Facility | Spanish
• CF - MH 3051b Feb. 2005: Notice of Right of Person on Voluntary Status to Request Discharge from a Treatment Facility | Spanish
• CF - MH 3057 Feb. 2005: Authorization for Electroconvulsive Treatment | Spanish
• CF - MH 3090 Feb. 2005: Petition for Writ of Habeas Corpus or for Redress of Grievances | Spanish
• CF - MH 3097 Feb. 2005: Application for Voluntary Admission - Minors | Spanish
• CF - MH 3098 Feb. 2005: Application for Voluntary Admission (State Treatment Facility) | Spanish
• CF - MH 3099 Feb. 2005: Certification of Ability to Provide Express and Informed Consent For Voluntary Admission and Treatment of Selected Persons From Facilities Licensed Under Chapter 400, F.S.
• CF - MH 3101 Feb. 2005: Hospital Determination That Person Does Not Meet Involuntary Placement Criteria
• CF - MH 3102 Feb. 2005: Request for Involuntary Examination After Stabilization of Emergency Medical Condition
• CF - MH 3103 Feb. 2005: Rights of Persons in Mental Health Facilities and Programs
• CF - MH 3104 Feb. 2005: Certification of Person's Competence to Provide Express and Informed Consent
• CF - MH 3105 Feb. 2005: Refusal or Revocation of Consent to Treatment | Spanish
• CF - MH 3106 Feb. 2005: Petition for Adjudication of Incompetence to Consent to Treatment and Appointment of a Guardian Advocate
• CF - MH 3107 Feb. 2005: Order Appointing Guardian Advocate
• CF - MH 3108 Feb. 2005: Petition Requesting Court Approval for Guardian Advocate to Consent to Extraordinary Treatment
• CF - MH 3109 Feb. 2005: Order Authorizing Guardian Advocate to Consent to Extraordinary Treatment
• CF - MH 3110 Feb. 2005: Restriction of Person's Access to Own Record | Spanish
• CF - MH 3111 Feb. 2005: Approval for Release of Person on Involuntary Status from a Receiving Facility
• CF - MH 3113 Feb. 2005: Notice to Court - Request for Continuance of Involuntary Placement Hearing
• CF - MH 3114 Feb. 2005: Order Requiring Involuntary Assessment and Stabilization for Substance Abuse and for Baker Act Discharge of Person 
• CF - MH 3115 Feb. 2005: Order Requiring Evaluation for Involuntary Outpatient Placement
• CF - MH 3116 Feb.2005: Findings and Recommended Order Restoring Person's Competence to Consent to Treatment and Discharging the Guardian Advocate
• CF - MH 3119 Feb. 2005: Notification of a Facility's Non-Compliance (Pursuant to Chapter 400, F.S.)
• CF - MH 3120 Feb. 2005: Certification of Guardian Advocate Training Completion
• CF - MH 3121 Feb. 2005: Notification to Court of Person's Competence to Consent to Treatment and Discharge of Guardian Advocate
• CF - MH 3122 Feb. 2005: Certification of Person's Incompetence to Consent to Treatment and Notification of Health Care Surrogate/Proxy | Spanish
• CF - MH 3123 Feb. 2005: Affidavit of Health Care Proxy | Spanish
• CF - MH 3124 Feb. 2005: Personal Safety Plan | Spanish
• CF - MH 3130 Feb. 2005: Petition for Involuntary Outpatient Placement
• CF - MH 3140 Sept. 2006: Designation of Service Provider for Involuntary Outpatient Placement
• CF - MH 3145 Sept. 2006: Proposed Individualized Treatment Plan for Involuntary Outpatient Placement and Continued Involuntary Outpatient Placement | Spanish
• CF - MH 3150 Feb. 2005: Notice to DCF of non-filing of Petition of Involuntary Outpatient Placement or Diminished Treatment Plan
• CF - MH 3155 Feb. 2005: Order for Involuntary Outpatient Placement or Continued Involuntary Outpatient Placement
• CF - MH 3160 Feb. 2005: Notice to Court of Modification to Treatment Plan for Involuntary Outpatient Commitment and/or Request for Approval of Material Modifications to Plan | Spanish
• CF - MH 3170 Feb. 2005: Petition for Termination of Involuntary Outpatient Placement Order | Spanish
• CF - MH 3180 Feb. 2005: Petition Requesting Authorization for Continued Involuntary Outpatient Placement
• CF - MH 3185 Feb. 2005: Notice to Court of Waiver of Continued Involuntary Outpatient Placement Hearing and Request for an Order
• CF - MH 7000 Jan. 1998: State Mental Health Facility Admission Form
• CF - MH 7001 Jan. 1998: State Mental Health Facility Discharge Form
• CF - MH 7002 Feb. 2005: 7002 Physician to Physician Transfer

Florida Baker Act Forms (Creole): (To be Updated)

• Florida Baker Overview (Creole)
• Application for Appointment of Independent Exper. (Creole)
• Notice of Right to Petition (Creole)
• Application for Voluntary Admission (Creole)
• General Authorization for Treatment Except Psych. (Creole)
• Specific Authorization for Psychotropic Medication (Creole)
• Inventory of Personal Effects (Creole)
• Authorization for Release of Information (Creole)
• Application for and Notice of Transfer (Creole)
• Restrictions of Communications or Visitors (Creole)
• Notice of Voluntary Patients Right to request (Creole)
• Notice of Voluntary Patients Right to request (Creole)
• Authorization for Electroconvulsive Treatment (Creole)
• Application for Voluntary Admissions - Minors (Creole)
• Application for Voluntary Admissions - State Treatment (Creole)
• Rights of Patients (Creole)
• Refusal or Revocation of Consent to Treatment (Creole)
• Certification of Guardian Advocate Training Comp. (Creole)
• Notification to Healthcare Surrogate (Creole)
• De-escalation Preference Form (Creole)