CARE-101 - Mental Health Declaration—CARE Act Proceedings

Summary

Mental Health Declaration—CARE Act Proceedings

Text

Form ID: CARE-101
Title: Mental Health Declaration—CARE Act Proceedings
Effective Date: 2024-09-01
Mandatory Form: yes
Languages: ភាសាខ្មែរ, 汉语, فارسی, 한국어, español, Tagalog, Tiếng Việt
Info Page: https://selfhelp.courts.ca.gov/jcc-form/CARE-101
Primary Download URL: https://www.courts.ca.gov/documents/care101.pdf
Alternate Download URLs: https://www.courts.ca.gov/documents/care101cm.pdf, https://www.courts.ca.gov/documents/care101c.pdf, https://www.courts.ca.gov/documents/care101f.pdf, https://www.courts.ca.gov/documents/care101k.pdf, https://www.courts.ca.gov/documents/care101s.pdf, https://www.courts.ca.gov/documents/care101t.pdf, https://www.courts.ca.gov/documents/care101v.pdf
Form Detail Page:
Mental Health Declaration—CARE Act Proceedings
(CARE-101)
A licensed behavioral health professional uses this form to tell the court that they have examined the respondent within 60 days of filing of the petition, or have made multiple attempts to examine, but have not been successful in conducting an examination within 60 days of the petition. A licensed behavioral health professional also uses this form to tell the court that they have determined that the respondent meets, or have reason to believe that the respondent meets, the legal requirements for CARE Act proceedings.
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ភាសាខ្មែរ
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فارسی
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(Vietnamese)
Effective: September 1, 2024
PDF Text:
CONFIDENTIAL
Form Adopted for Mandatory Use 
Judicial Council of California 
CARE-101 [Rev. September 1, 2024]
Welfare & Institutions Code, 
§§ 5971, 5972, 5975, 5977 MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS
CARE-101
ATTORNEY OR PARTY WITHOUT ATTORNEY STATE BAR NUMBER:
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:
BRANCH NAME:
CITY AND ZIP CODE:
CARE ACT PROCEEDINGS FOR (name):
RESPONDENT
MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS
FOR COURT USE ONLY
CASE NUMBER:
TO LICENSED BEHAVIORAL HEALTH PROFESSIONAL 
This form will be used to help the court determine whether 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.
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 (check one):
(1) I am employed as a psychologist clinical social worker continuing my employment in the 
same class as of January 1, 1979, in the same program or facility.
(2) I am registered with the licensing board of the State Department of Health Care Services for the purpose of acquiring 
the experience required for licensure and employed or under contract to provide mental health services as a (check 
one):
(a) clinical social worker.
(b) marriage and family therapist.
(c) professional clinical counselor.
(3) I am employed or under contract to provide mental health services as a psychologist who is gaining experience 
required for licensure.
Page 1 of 4

CONFIDENTIAL
CARE-101 [Rev. September 1, 2024]
MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS
CARE-101
CARE ACT PROCEEDINGS FOR (name):
RESPONDENT
CASE NUMBER:
3. b. (4) I have been recruited for employment from outside this state, and my experience is sufficient to gain admission to a 
California licensing examination. I am employed or under contract to provide mental health services as a (check one):
(a) psychologist.
(b) clinical social worker.
(c) marriage and family therapist.
(d) professional clinical counselor.
4. Respondent (name):
is is not a patient under my continuing care and treatment.
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 of a schizophrenia spectrum disorder or another psychotic disorder in the same class (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 diagnosis of 
schizophrenia spectrum or other 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):
Page 2 of 4

CONFIDENTIAL
CARE-101 [Rev. September 1, 2024]
MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS
CARE-101
CARE ACT PROCEEDINGS FOR (name):
RESPONDENT
CASE NUMBER:
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 (explain in detail):
At least one of these is true (complete one or both of the following):d.
(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):
Page 3 of 4

CONFIDENTIAL
CARE-101 [Rev. September 1, 2024]
MENTAL HEALTH DECLARATION—CARE ACT PROCEEDINGS
Page 4 of 4
CARE-101
CARE ACT PROCEEDINGS FOR (name):
RESPONDENT
CASE NUMBER:
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)

Retrieval chunks

• #1

  Form ID: CARE-101 Title: Mental Health Declaration—CARE Act Proceedings Effective Date: 2024-09-01 Mandatory Form: yes Languages: ភាសាខ្មែរ, 汉语, فارسی, 한국어, español, Tagalog, Tiếng Việt Info Page: https://selfhelp.courts.ca.gov/jcc-form/CARE-101 Primary Download URL: https://www.courts.ca.gov/documents/care101.pd…

• #2

  This form will be used to help the court determine whether 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 profession…

• #3

  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…

• #4

  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…