DMH 5-72-19-Integrated-First-IVC-Exam eff 12.6.23 rev 8.16.24

Sep 21, 2026

Uploaded by Stanley

First Examination for Involuntary Commitment form from the State of North Carolina Department of Health and Human Services, Division of Mental Health, Developmental Disabilities, and Substance Use Services. Collects respondent identity details, examination timing, in-person versus telemedicine method, and assessment elements for mental illness, intellectual disability, substance abuse, dangerousness, and capacity to make an informed treatment decision. Includes Section I commitment criteria options (inpatient, outpatient, substance abuse), telemedicine certification note, and Section II description fields, plus health screening guidance with vital signs, problems, allergies, medications, and emergency escalation triggers and consult requirements.

LanguageEnglish

CategoryExam

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

EXAMINATION INFORMATION

SECTION I – CRITERIA FOR COMMITMENT

SECTION II – DESCRIPTION OF FINDINGS

HEALTH SCREENING

STATE OF NORTH CAROLINA Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Use Services FIRST EXAMINATION FOR INVOLUNTARY COMMITMENT County Client Record \# File \# | Name of Respondent | DOB | | Age | | Sex | | Race | M.S. | | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Address (Street or Box Number) | City | | State | Zip | | County | | | Phone | | Legally Responsible Person or Next of Kin (Name) | | Relationship | | | | | | | | | Address (Street or Box Number) | City | | State | Zip | | County | | | Phone | | Petitioner (Name) | | Relationship | | | | | | | | | Address (Street or Box Number) | City | | State | Zip | | County | | | Phone | | EXAMINATION INFORMATION | | --- | | The First-Level examination and evaluation for the above-named respondent: | | was conducted on / / (MM/DD/YYYY) at : ☐ A.M. ☐ P.M. | | was conducted:
☐ In person at the following facility OR ☐ Via telemedicine technology | | Included in the examination was an assessment of the respondent’s:
☐ (1) Current and previous mental illness and intellectual disability including, if available, previous treatment history; (2) Dangerousness to self or others as defined in G. S. 122C-3 (11*); (3) Ability to survive safely without inpatient commitment, including the availability of supervision from family , friends, or others; and (4) Capacity to make an informed decision concerning treatment.
☐ (1) Current and previous substance abuse including, if available, previous treatment history; and (2) Dangerousness to self or others as defined in G. S. 122C-3 (11*) . | The following findings and recommendations are made based on this examination^: | SECTION I – CRITERIA FOR COMMITMENT | | | | --- | --- | --- | | It is my opinion that the respondent meets the criteria for the selected type of commitment as the respondent is: | | | | ☐ Inpatient
(1st Exam– Commitment Examiner, eligible Psychologist or Physician)
☐ An individual with a mental illness;
☐ Dangerous to:☐Self or ☐Others;
☐ In addition to having a mental illness is also intellectually disabled;
☐ None of the above | ☐ Outpatient (1st Exam– Commitment Examiner, eligible Psychologist or Physician)
☐ An individual with a mental illness;
☐ Capable of surviving safely in the community with available supervision;
☐ Based upon the respondent’s treatment history, the respondent is in need of treatment in order to prevent further disability or deterioration which would predictably result in dangerousness as defined by G.S. 122C-3 (11*);
☐ Current mental status or the nature of his/her illness limits or negates his/her ability to make an informed decision to seek treatment voluntarily or comply with recommended treatment;
☐ None of the above | ☐ Substance Abuse
(1st Exam– LCAS CE, eligible Psychologist or Physician)
☐ A Substance Abuser;
☐ Dangerous to:☐Self or ☐Others;
☐ None of the above | ^Fortelemedicine evaluations only: ☐ I certify to a reasonable degree of medical certainty that the results of the examination via telemedicine were the same as if I had been personally present with the respondent OR ☐ The respondent needs to be taken for a face-to-face evaluation. (*Statutory definitions begin on page 3) | Name of Respondent: | DOB: | | --- | --- | | SECTION II – DESCRIPTION OF FINDINGS | | | Clear description of findings (findings for each criterion checked in Section I must be described): | | | Impression/Diagnosis: | | | HEALTH SCREENING | | | A health screening (N. C. G. S. § 122C-3(16a)) does not constitute a medical evaluation† and should be completed at the same location as the first examination or by utilizing telemedicine equipment and procedure (N. C. G. S.§ 122C-263(a1)). | | | ☐ Check box & sign to attest that the health screening is being replaced by a medical evaluation† skip to Section III
Sign

FAQs

What are the main assessment topics included in the first-level examination?

The examination includes assessment of current and previous mental illness and intellectual disability (including prior treatment history if available), dangerousness to self or others, ability to survive safely without inpatient commitment, and capacity to make an informed decision about treatment. It also covers current and previous substance abuse and dangerousness to self or others.

How does the form address telemedicine examinations?

It records whether the examination was conducted in person or via telemedicine. For telemedicine evaluations only, the form includes a certification statement confirming results match what would occur if personally present, or indicates the respondent needs a face-to-face evaluation.

When does the health screening require sending the respondent to an Emergency Department?

If any specified high-risk items are present, the form directs checking the box and sending the respondent to an Emergency Department by the most appropriate means. Examples listed include chest pain or shortness of breath, suspected overdose within 24 hours, severe pain, disorientation or inability to maintain balance, head trauma or loss of consciousness, recent trauma or profuse bleeding, and neurological or visual changes.

Sep 21, 2026

Uploaded by Stanley