APPLICATION FOR HEARING BEFORE THE PSYCHIATRIC SECURITY REVIEW BOARD In the Matter

Of

CLIENT

I, REQUESTOR, request that the Psychiatric Security Review Board conduct a hearing in this case. My relation the CLIENT is Indicate relationship or “Self”.

I believe the Board should take the following action at this hearing (may check more than one):

☐	Discharge the named client from the jurisdiction of the Psychiatric Security Review Board.

☐	Release the named client from the hospital on conditional release.

☐	Other: OTHER.

III.	The reasons this action should be taken at a hearing are:

☐	The person is no longer affected by a qualifying mental disorder.

☐	The person is no longer a substantial danger to others, and there is not a

reasonable medical probability of the person becoming dangerous.

☐	The person could be controlled with treatment on conditional release and a

conditional release plan is being prepared.

☐	Other: OTHER.

IV.	Basic Information

Client’s current campus: ☐Salem	☐Junction City

Client’s current unit: Unit

Client’s current prescriber: Prescriber

Client’s current social worker: Social Worker

Does client require an interpreter for the PSRB hearing? ☐ YES	☐ NO

Please describe any changes anticipated within the next 60 days e.g. campus, unit, social worker, prescriber

IV.	For requests for conditional release only:

☐	A written community evaluation was submitted to the Board.

☐	A signed Summary of Conditional Release Plan has been submitted to the Board.

☐	Name of the prospective community placement: PLACEMENT

☐	A prescriber-to-prescriber consult is planned with NAME OF PRESCRIBER on DATE

☐	Date the prospective community placement anticipates a vacancy: DATE.

Signature of the person submitting this form:

Prescriber consultations are required to take place within 30 days prior to the hearing.