Preview
FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135
NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023
NewYorleslate
ormOMH474A476A(1hi) oflicaof MentalHealth
Person'sName(Last First, M.I.) a ? No.
C.P.E.P.**
EMERGENCY or EMERGENCY ADMISSION
(Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygl ine Law) -- --------......
Custody/Transport of a Person sex ----------- tie. of alsth.H.
Alleged To Be Mentally 111To A Hospital Apg: roved
To Receive Emergency or C.P.E.P. Ernergency A imissions
Address
.f &2%,âxE....3)..24.91r
l. § 9.41 Mental Hygiene.Law Custodynransport By Certain Peace Officers and Police Officers
1, A1c.üots 3wet
(name)
. a I'eace Officer/Police Officer of N0 VMt 579177
(Departmentionation
hereby acknowledge that I have taken into custody , " T To Yi
LC , who a pears to be
of Person)
mentally ill and is conducting him/herself in a manner which is likely to result in serious thers.*
harm to him/herself or
A. I have removed or directed the removal of this >erson to tw 674 L.
(Nameof §9.39HospitakC
P.EP.*")
OR
B. I am temporarity this person at
detaining , a safe and comfortablo place,
pending examination or admission to . I am notifying
(NTnaof19.39Hospital/C.P.EP."*) (Direneror Couununty
or Services)
of o
(Healthomcer] (cRy) (county)
of this detention/removal.
signatureofPeaceomcertPolloe
omcar TitlesadgeNumber
f.wn..----·7 . Mo Day Yr. r. M n
IL BA5 Mental Hygiene Law Reques By A Director of Community Services or Designee
1, , am the Di ector of Community Services for
(Meme)
(CRyor O pnty)
I. , am the desitnee of the Director of Community Services for .
(Nane)
it has been reported ( hyor6
to rne that , has a mental illness for which immediate of and treatment
in a hospital is appropria te and which is likely to res aft In serious harm to him/herself or others.*
This information has been reported to me by , who is:
(Name)
O a licensed physician a a police officer a the adult sibling of the person
O a licensed psychologist, 3 a peace officer with O the committee or lega I guardian
registered professional nurse, appropriate special duties of the person
or licensed social worker currently responsible 3 the spouse of the person a the supportive case n anager
for providing treatrnent services to the person a the child of the person of the person***
O a health officer J the parent of the person a the intensive case ma nager
person***
of the
1 hereby direct, under section 9.45 of the Mental Hygie le Law, that peace/police officers of
take this person (DepartmentA.c
mation)
into custody and transport him/her to
(Nameof99.39HospitallCP.E.P")
OR
I hereby request, under section 9.45 of the Mental Hys iene Law, that transport this person to
of59.39HospEsUCP.E
(Harne P")
Signature
qioboetorof Community
Servlcesor Designae
OAM
Mp fhly fviln OPM
"l.Jhelytorenunlaserlops horrn"reasrtst(a) a substantialriskofphystoninormtothepersonasmanifested Hr
by threatsofor attenytsatsulchieor seriousbodilyItarmof o178 IConductdemonstrating
matthepersonis dangaraum toblinsaifor hersett(*curerconduct"shadinctmfethepa son'srefusalor Inebnl(
y tomeetbleor heressenGal neecrtbt ibo,t.abaner,
stothRry, orI earthcase,guovided llint
SuchrentsalorAnnhinyle Mkelyinstanubrseriousharrn5 thereUStwl kninacMate of (b) a mobslentist
hosp*aHeaNorgi. riskat physicalharmfo otherperscoaasmanifested
eenavior1ay whichsthersareplacedIrrreasonablefearofseriousphysicalharm. by I emicidstorothervident
"A hospitalapproved by theCtxttmisaloner of OMH,underMHLSection9.39,as maiitainingadequatestaffandracMiesfor aderlining pallentsonan emergency
Inprovidapsychiatrioantergency servicestopatientsadmittedunderMHLSection9.4 . basis,or.a CP.E.P.licensetiby DMH
-includ-a asupporuv.orat---r-
beenapproved by theomesat Mangal
-.n-n-e- -na -a- in. "ppris-mi.quarance oroasianrieneo
HeaAhforthe pusposeof reportingundctthiss atlan(MHL§9AS).
oyoivru,andwnomasmeenassigrietrto a personbr a caseenieriagert entprogram whicrihas
FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135
NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023
MVHS Rev 4 (I 29/23)
Pag 1 of 2
* L. D 2 * 4.
(Oneida County)
Law Enforcement Request For Examination
To: "The Wynn Hospital
TYPE: 9.41 O9A5 9.55 ¡ 22.05 O Other (specify)
Police Agency: 0 yea arorsp.,x Incident # 7>84/3 Officers Name AlinKm P97£/7
Date: u /4/T3 Time of Complaint: it Q O AM BPM Time of Transport
f.'
/ ( AM ¤ PM
Ambulance Co: PstTY½ ( noq t M c ord
Location nf Incident· 14 C WA foG/\ J cas.Q o 3
Last Name (1L First Name 24, -rT,sfy
y
ul
Address (Street) 4 C gy-aryce o .·v L rd vvao City | w rersev.ots. | state --1
Telephone DOE 7-
9 2, aa(a y 4
f
Q{r Sex| FC,vvg-g Age
IS EDP A MINOR? No If yes, Part nt/Guardian must child to ED.
OYes, accompany
If Yes, Parent/Guardian Name: Phone Numbers:
Parent Guaidian Address: O Same as EDP O Other:
Homeless No OYes OUnk
laterpreter Needed? No OUnk ¤Yes S ecify Language
What was reported to Police about the EDP's bel avior?
PotJSost&A 1-oa maw TNPPRPWord (Y\f Ik e erT.a ; tiv
TFn/Tro8Athf
Name of Soume: ho/W IUE PhoneNumber of Source: 2*S 99 N !I? 4 */
(Ly
Relationship to Subject: N\o Tt·i-£A
Officers Observation of EDP's behavior:
Lvi THft R#p (-
Weapons Check: EDP Searched ? ¤No Yes . Weapons Found? No Yes (specify)
Disposition:
Potential for Violence? Y N
Restmints/Guffs Used?
O Y N
A. Other agency/service involvement:
Current Mental Health /Service Providers: No Unk Yes
Providers Name: Agency
Phone No.: Consulted? No ¤ Yes
B. MCAT Called? (315-732-6228) 4-
No, Reason
Yes MCAT staff Name:
Responded to scene? ¤ No
Response/Reason
Yes: if yes, response time from time of call to a Tival (duration minutes)
C. FOR 22.09
Altemative safe location for client available? No ¤Unknown Yes
Comments:
Addiction
No - Reason:
Crisis Center Contacted (ACC) (315-735 1645 ext 162 or 163) Called? O NA
Yes. Wbrker Name:
Response/ reason for refusal:
FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135
NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023
MVH
utica, NY Rav4 (W2974)
MVHs,hic, Page 2 of 2
(Oneida County)
Law Enfo pement Request For Examination
L NAME E ( ( F NAME: 20t77 DOB: 9 / 4 W/
Jy
BEHAVIOI4S/ACTIONS INDICATING THAT PERSON l^ A DANGER TO SELF/OTHERS (CHECK
ALL THATIAPPLY):
Places se f in dangerous situations Unable to Care for St if Presence of weapons/dangerous
Ibal th Of harm 10 self Physical gestures of I arm to self attempted to harm self
erbal th ats of harm to others Physical gestures of I arm to others attempted to harm others
Specify
CHECK AL . BEHAVIORS OF EDP THAT ARE EITHER OE SERVED (0) OR REPÇRTED (R):
R VER AL/BEHAVIORAL O APPEARANCE AND BEHAVIOR
INCO ERENT/ILLOGICAL SPEECH CONFUSEDCISORIENTED
TALKI G TO SELF SAD EXPRESS©N/CRYING
FAILU E TO RESPOND TO QUESTIONS PRESENCE OF FECES/URINE
REPO TED HEARING VOICES ,BLOODSi-lOT EYES
SLUR ED SPEECH SUSPICIOUSNESS
EXTR EME RAPID/UNCONTROLLED SPEECH HYPERACTIVITY
EXTREME SLOW SPEECH NODDING OUT
] HOST LE/AGRUMENTATIVE BELLIGERANT PROFUSE SWEATING
REPEATED LOUD YELLING APPEARS INSENSITIVE TO PAIN
OVE Y SUSPICIOUS/FEELINGS OF PERSECUTON DRESS INCONSISTENT TO WEATHER
TALK REPEATEDLY ABOUT A SINGLE SUBJECT EXHIBITS EXTRAORDINARY STRENGTH
EXPR SSES IDEAS OF INFLATED SELF-WORTH O RAPID HEART RATE/RESPIRATION
] TALK REPEATEDLY ABOUT DEATH
SUBSTANCE ABUSE INDICATORS BREATH ANALYSIS RESULT:
O Time of Test: Dam Opm
OPE UG CONTAINERS .
ALCO OL CONTAINERS
CRAC VIALS
GLASSINE ENVELOPES
HYPO ERMIC NEEDLES
ADM TO/REPORTED USE OF(SPECIFY):
OTHE DESCRIBE:
CRIMINALICHARGES: Criminal Charges Placed? No ¤Yes,Charge:
Appearance icket Issued ? 0No ¤ Yes
Order of P ection in Force? No ¤Yes Details:
IF EDP doe not require Inpatient Psychiatric/Medical Services, si ould delivering police agency be notified
plior to rel ? NO ¤YES, Police Agency Contact Name/ vumber
.'
Time IN ED: 4D AM PM Time Out 4: ¤ AM ¤ PM
enforcement: o569H "TXA0 /4 . D .
SIGNATUR of ED RN/MD releasing Law
ROUUNG: COPY TO ED, 1 COPY TO LAW ENFORCEME T, I COPY TO COUNTY COMMISSIONER OF
MENTAL H LTH: Oneida County MH fax- 315-768-367o (phon 315-768-3680)/ Herkimer County MH Fax·
315-867-14 9 (phone 315-867-1485) For 9.41/45/55 Include Leg 11forms with routing.
Faxed to Di ector of Mental Health Oneida Herkimer
By. 7 .' et Omcer Signature Pf me
Preview
FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023 NewYorleslate ormOMH474A476A(1hi) oflicaof MentalHealth Person'sName(Last First, M.I.) a ? No. C.P.E.P.** EMERGENCY or EMERGENCY ADMISSION (Sections 9.41, 9.45, 9.55 and 9.57 Mental Hygl ine Law) -- --------...... Custody/Transport of a Person sex ----------- tie. of alsth.H. Alleged To Be Mentally 111To A Hospital Apg: roved To Receive Emergency or C.P.E.P. Ernergency A imissions Address .f &2%,âxE....3)..24.91r l. § 9.41 Mental Hygiene.Law Custodynransport By Certain Peace Officers and Police Officers 1, A1c.üots 3wet (name) . a I'eace Officer/Police Officer of N0 VMt 579177 (Departmentionation hereby acknowledge that I have taken into custody , " T To Yi LC , who a pears to be of Person) mentally ill and is conducting him/herself in a manner which is likely to result in serious thers.* harm to him/herself or A. I have removed or directed the removal of this >erson to tw 674 L. (Nameof §9.39HospitakC P.EP.*") OR B. I am temporarity this person at detaining , a safe and comfortablo place, pending examination or admission to . I am notifying (NTnaof19.39Hospital/C.P.EP."*) (Direneror Couununty or Services) of o (Healthomcer] (cRy) (county) of this detention/removal. signatureofPeaceomcertPolloe omcar TitlesadgeNumber f.wn..----·7 . Mo Day Yr. r. M n IL BA5 Mental Hygiene Law Reques By A Director of Community Services or Designee 1, , am the Di ector of Community Services for (Meme) (CRyor O pnty) I. , am the desitnee of the Director of Community Services for . (Nane) it has been reported ( hyor6 to rne that , has a mental illness for which immediate of and treatment in a hospital is appropria te and which is likely to res aft In serious harm to him/herself or others.* This information has been reported to me by , who is: (Name) O a licensed physician a a police officer a the adult sibling of the person O a licensed psychologist, 3 a peace officer with O the committee or lega I guardian registered professional nurse, appropriate special duties of the person or licensed social worker currently responsible 3 the spouse of the person a the supportive case n anager for providing treatrnent services to the person a the child of the person of the person*** O a health officer J the parent of the person a the intensive case ma nager person*** of the 1 hereby direct, under section 9.45 of the Mental Hygie le Law, that peace/police officers of take this person (DepartmentA.c mation) into custody and transport him/her to (Nameof99.39HospitallCP.E.P") OR I hereby request, under section 9.45 of the Mental Hys iene Law, that transport this person to of59.39HospEsUCP.E (Harne P") Signature qioboetorof Community Servlcesor Designae OAM Mp fhly fviln OPM "l.Jhelytorenunlaserlops horrn"reasrtst(a) a substantialriskofphystoninormtothepersonasmanifested Hr by threatsofor attenytsatsulchieor seriousbodilyItarmof o178 IConductdemonstrating matthepersonis dangaraum toblinsaifor hersett(*curerconduct"shadinctmfethepa son'srefusalor Inebnl( y tomeetbleor heressenGal neecrtbt ibo,t.abaner, stothRry, orI earthcase,guovided llint SuchrentsalorAnnhinyle Mkelyinstanubrseriousharrn5 thereUStwl kninacMate of (b) a mobslentist hosp*aHeaNorgi. riskat physicalharmfo otherperscoaasmanifested eenavior1ay whichsthersareplacedIrrreasonablefearofseriousphysicalharm. by I emicidstorothervident "A hospitalapproved by theCtxttmisaloner of OMH,underMHLSection9.39,as maiitainingadequatestaffandracMiesfor aderlining pallentsonan emergency Inprovidapsychiatrioantergency servicestopatientsadmittedunderMHLSection9.4 . basis,or.a CP.E.P.licensetiby DMH -includ-a asupporuv.orat---r- beenapproved by theomesat Mangal -.n-n-e- -na -a- in. "ppris-mi.quarance oroasianrieneo HeaAhforthe pusposeof reportingundctthiss atlan(MHL§9AS). oyoivru,andwnomasmeenassigrietrto a personbr a caseenieriagert entprogram whicrihas FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023 MVHS Rev 4 (I 29/23) Pag 1 of 2 * L. D 2 * 4. (Oneida County) Law Enforcement Request For Examination To: "The Wynn Hospital TYPE: 9.41 O9A5 9.55 ¡ 22.05 O Other (specify) Police Agency: 0 yea arorsp.,x Incident # 7>84/3 Officers Name AlinKm P97£/7 Date: u /4/T3 Time of Complaint: it Q O AM BPM Time of Transport f.' / ( AM ¤ PM Ambulance Co: PstTY½ ( noq t M c ord Location nf Incident· 14 C WA foG/\ J cas.Q o 3 Last Name (1L First Name 24, -rT,sfy y ul Address (Street) 4 C gy-aryce o .·v L rd vvao City | w rersev.ots. | state --1 Telephone DOE 7- 9 2, aa(a y 4 f Q{r Sex| FC,vvg-g Age IS EDP A MINOR? No If yes, Part nt/Guardian must child to ED. OYes, accompany If Yes, Parent/Guardian Name: Phone Numbers: Parent Guaidian Address: O Same as EDP O Other: Homeless No OYes OUnk laterpreter Needed? No OUnk ¤Yes S ecify Language What was reported to Police about the EDP's bel avior? PotJSost&A 1-oa maw TNPPRPWord (Y\f Ik e erT.a ; tiv TFn/Tro8Athf Name of Soume: ho/W IUE PhoneNumber of Source: 2*S 99 N !I? 4 */ (Ly Relationship to Subject: N\o Tt·i-£A Officers Observation of EDP's behavior: Lvi THft R#p (- Weapons Check: EDP Searched ? ¤No Yes . Weapons Found? No Yes (specify) Disposition: Potential for Violence? Y N Restmints/Guffs Used? O Y N A. Other agency/service involvement: Current Mental Health /Service Providers: No Unk Yes Providers Name: Agency Phone No.: Consulted? No ¤ Yes B. MCAT Called? (315-732-6228) 4- No, Reason Yes MCAT staff Name: Responded to scene? ¤ No Response/Reason Yes: if yes, response time from time of call to a Tival (duration minutes) C. FOR 22.09 Altemative safe location for client available? No ¤Unknown Yes Comments: Addiction No - Reason: Crisis Center Contacted (ACC) (315-735 1645 ext 162 or 163) Called? O NA Yes. Wbrker Name: Response/ reason for refusal: FILED: ONEIDA COUNTY CLERK 12/05/2023 12:14 PM INDEX NO. EFCA2023-003135 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 12/05/2023 MVH utica, NY Rav4 (W2974) MVHs,hic, Page 2 of 2 (Oneida County) Law Enfo pement Request For Examination L NAME E ( ( F NAME: 20t77 DOB: 9 / 4 W/ Jy BEHAVIOI4S/ACTIONS INDICATING THAT PERSON l^ A DANGER TO SELF/OTHERS (CHECK ALL THATIAPPLY): Places se f in dangerous situations Unable to Care for St if Presence of weapons/dangerous Ibal th Of harm 10 self Physical gestures of I arm to self attempted to harm self erbal th ats of harm to others Physical gestures of I arm to others attempted to harm others Specify CHECK AL . BEHAVIORS OF EDP THAT ARE EITHER OE SERVED (0) OR REPÇRTED (R): R VER AL/BEHAVIORAL O APPEARANCE AND BEHAVIOR INCO ERENT/ILLOGICAL SPEECH CONFUSEDCISORIENTED TALKI G TO SELF SAD EXPRESS©N/CRYING FAILU E TO RESPOND TO QUESTIONS PRESENCE OF FECES/URINE REPO TED HEARING VOICES ,BLOODSi-lOT EYES SLUR ED SPEECH SUSPICIOUSNESS EXTR EME RAPID/UNCONTROLLED SPEECH HYPERACTIVITY EXTREME SLOW SPEECH NODDING OUT ] HOST LE/AGRUMENTATIVE BELLIGERANT PROFUSE SWEATING REPEATED LOUD YELLING APPEARS INSENSITIVE TO PAIN OVE Y SUSPICIOUS/FEELINGS OF PERSECUTON DRESS INCONSISTENT TO WEATHER TALK REPEATEDLY ABOUT A SINGLE SUBJECT EXHIBITS EXTRAORDINARY STRENGTH EXPR SSES IDEAS OF INFLATED SELF-WORTH O RAPID HEART RATE/RESPIRATION ] TALK REPEATEDLY ABOUT DEATH SUBSTANCE ABUSE INDICATORS BREATH ANALYSIS RESULT: O Time of Test: Dam Opm OPE UG CONTAINERS . ALCO OL CONTAINERS CRAC VIALS GLASSINE ENVELOPES HYPO ERMIC NEEDLES ADM TO/REPORTED USE OF(SPECIFY): OTHE DESCRIBE: CRIMINALICHARGES: Criminal Charges Placed? No ¤Yes,Charge: Appearance icket Issued ? 0No ¤ Yes Order of P ection in Force? No ¤Yes Details: IF EDP doe not require Inpatient Psychiatric/Medical Services, si ould delivering police agency be notified plior to rel ? NO ¤YES, Police Agency Contact Name/ vumber .' Time IN ED: 4D AM PM Time Out 4: ¤ AM ¤ PM enforcement: o569H "TXA0 /4 . D . SIGNATUR of ED RN/MD releasing Law ROUUNG: COPY TO ED, 1 COPY TO LAW ENFORCEME T, I COPY TO COUNTY COMMISSIONER OF MENTAL H LTH: Oneida County MH fax- 315-768-367o (phon 315-768-3680)/ Herkimer County MH Fax· 315-867-14 9 (phone 315-867-1485) For 9.41/45/55 Include Leg 11forms with routing. Faxed to Di ector of Mental Health Oneida Herkimer By. 7 .' et Omcer Signature Pf me