Orange — CARE 101 – Mental Health Declaration

Source: https://courts.ca.gov/sites/default/files/courts/default/2024-11/care101.pdf

CONFIDENTIAL CARE-101 ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER: FOR COURT USE ONLY NAME: FIRM NAME: STREET ADDRESS: CITY: STATE: ZIP CODE: TELEPHONE NO.: FAX NO.: EMAIL ADDRESS: ATTORNEY FOR (name): SUPERIOR COURT OF CALIFORNIA, COUNTY OF STREET ADDRESS: MAILING ADDRESS: CITY AND ZIP CODE: BRANCH NAME: CARE ACT PROCEEDINGS FOR (name):

RESPONDENT CASE NUMBER:

MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS

TO LICENSED BEHAVIORAL HEALTH PROFESSIONAL

This form will be used to help the court determine whether the respondent meets the diagnostic criteria for CARE Act proceedings.

GENERAL INFORMATION

1. Declarant's name:

2. Office address, telephone number, and email address:

3. License status (complete either a or b): a. I am a licensed behavioral health professional and conducting the examination described on this form is within the scope of my license. I have a valid California license as a (check one): (1) physician. (2) psychologist. (3) clinical social worker. (4) marriage and family therapist. (5) professional clinical counselor. (6) nurse practitioner. (7) physician assistant.

   b. I have been granted a waiver of licensure by the State Department of Health Care Services under Welfare and Institutions Code section 5751.2 because (explain):

   c. My license number is (if applicable):

4. Respondent (name): is is not a patient under my continuing care and treatment.

Judicial Council of California, courts.ca.gov Rev. July 1, 2026, Mandatory Form CARE-101, Page 1 of 4 Welf. & Inst. Code, §§ 5971, 5972, 5975, Mental Health Declaration—CARE Act Proceedings 5977

CONFIDENTIAL CARE-101 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

EXAMINATION OR ATTEMPTS MADE AT EXAMINATION OF RESPONDENT

5. Complete one of the following (both a and b must be within 60 days of the filling of the CARE Act petition): a. I examined the respondent on (date): (proceed to item 7). b. On the following dates: I attempted to examine respondent but was unsuccessful due to respondent's lack of cooperation in submitting to an examination.

6. (Answer only if item 5b is checked.) Explain in detail when, how many attempts, and the types of attempts that were made to examine respondent. Also explain respondent's response to those attempts and the outcome of each attempt.

7. Based on the following information, I have reason to believe respondent meets the diagnostic criteria for CARE Act proceedings (each of the following requirements must be met for respondent to qualify for CARE Act proceedings): a. Respondent has a diagnosis as defined in the current Diagnostic and Statistical Manual of Mental Disorders of a schizophrenia spectrum disorder or another psychotic disorder in the same class, or bipolar I disorder with psychotic features, except psychosis related to current intoxication (indicate the specific disorder):

   Note: Under Welfare and Institutions Code section 5972, a qualifying psychotic disorder must be primarily psychiatric in nature and not due to a medical condition such as a traumatic brain injury, autism, dementia, or a neurological condition. A person who has a current diagnosis of substance use disorder without also meeting the other statutory criteria, including a psychotic disorder, does not qualify.

   b. Respondent is experiencing a serious mental disorder that (all of the following must be completed): (1) Is severe in degree and persistent in duration (explain in detail):

Rev. July 1, 2026 CARE-101, Page 2 of 4 Mental Health Declaration—CARE Act Proceedings

CONFIDENTIAL CARE-101 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

7. b. (2) May cause behavior that interferes substantially with the primary activities of daily living (explain in detail):

   (3) May result in an inability to maintain stable adjustment and independent functioning without treatment, support, and rehabilitation for a long or indefinite period (explain in detail):

   c. Respondent is not clinically stabilized in ongoing voluntary treatment. A respondent is clinically stabilized in ongoing treatment if both of the following are true: (1) The respondent's condition is stable and not deteriorating; and (2) The respondent is currently engaged in treatment and managing symptoms through medication or other therapeutic interventions. (Explain in detail):

   d. At least one of these is true (complete one or both of the following): (1) Respondent is unlikely to survive safely in the community without supervision and respondent's condition is substantially deteriorating (explain in detail): (2) Respondent needs services and supports to prevent a relapse or deterioration that would likely result in grave disability or serious harm to respondent or others (explain in detail):

Rev. July 1, 2026 CARE-101, Page 3 of 4 Mental Health Declaration—CARE Act Proceedings

CONFIDENTIAL CARE-101 CARE ACT PROCEEDINGS FOR (name): CASE NUMBER:

RESPONDENT

7. e. Participation in a CARE plan or CARE agreement would be the least restrictive alternative necessary to ensure respondent's recovery and stability (explain in detail):

   f. Respondent is likely to benefit from participation in a CARE plan or CARE agreement (explain in detail):

8. Additional information regarding my examination of respondent is as follows on Attachment 8.

I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Date:

Type or Print Declarant's Name Signature of Declarant

Rev. July 1, 2026 CARE-101, Page 4 of 4 Mental Health Declaration—CARE Act Proceedings For your protection and privacy, please press the Clear button after you have printed the form. Print Save Clear