Policy Text
TODD ELGIN, CHIEF OF POLICE
Professional Standards Division NUMBER: 201 9-01
ISSUED: January 15, 2019
This training bulletin is to assist you as a guide in completing the new DHCS 1801 (06/18)
forms, a.k.a. WIC 5150 form. These new forms are to replace the old one -page WIC 5150
form beginning on January 1, 2019. This bulletin provides explanations in simple terms
as to how to complete each category. Please refer to the following information and
attachment regarding the completion of this form .
Application for assessment, evaluation, and crisis intervention or placement for
evaluation and treatment - DHCS 1801 (06/18)
Page 1 of 4:
This page remains (visually) in the same format as the previous version. The font has
increased and additional lines have been added to appropriately document the incident
information. Write the GGP D Incident Number (i.e. 19012345) at the top of the form, and
at the top of all pages included.
Detainment Advisement : Print your name on this line (Officer John Doe)
Advisement Complete/Incomplete : Check the appropriate box
Good cause for Incomplete Advisement : This section should only be completed in cases
when the subject is not conscious, not present due to emergency transportation, or
extreme circumstances not listed. Officers shall take appropriate measures to document
this advisement via audio/v isual recording devises when safe to do so.
Advisement Completed By : Print your name (Officer John Doe)
Position : “Police Officer”
Language or Modality Used : Examples “English”, “Spanish”, etc.
Date of Advisement : Date of Detainment
To (name of 5150 Desi gnated facility) : “Any designated Facility” (See attached example)
Application is hereby made for the assessment and evaluation of : (Subject’s name)
Residing at : Subject’s address (“Homeless” or “Unknown” is acceptable) TRAINING BULLETIN
*If subject is a juvenile (WIC 5585 ), check the appropriate box for the legally
responsible party (i.e. Parent, Legal Guardian, Conservator, Juvenile Court (WIC
300), etc). Be sure to collect contact information for the legally responsible party
for all juveniles and list this information i n the section below.
The above person’s condition was called to my attention under the following
circumstances : (Why did you get called out?) Example – Family contacted GGPD
describing subject as verbally threatening to kill family and posturing with a ha mmer.
Family reports fearing for their safety.
I have probable cause to believe that the person is, as a result of mental health disorder,
a danger to others, or to himself/herself, or gravely disabled because : What is the subject
doing or saying that sup ports the criteria for (DTS, DTO, or GD)? This section must be
specific as to the actions, statements and/or observations of the officer(s) or witnessing
parties. Detail the subject’s steps taken in furtherance of threats to self/others, judgment,
impulse control, visual or auditory command hallucinations, confusion, disorientation,
unwilling or inability to respond to officer(s) questions, perceptions of surroundings, self -
care measures (i.e. food, water and/or emergency medical care needs, including but n ot
limited to vital medication). If situation dictates, include: “Inappropriate for voluntary
hospitalization” due to the above factors.
Page 2 of 4:
Historical course of the person’s mental disorder : *Important note: this is not your
(officer) determination. This section shall apply to self -admission, family or close
associate information provided, documentation listing the diagnoses, or other trustworthy
information provided to the officer(s) at the time of detainment. This can include previous
suicide or homicidal attempts, previous hospitalization under WIC 5150, history of
incarcerations related to behavioral health.
If “No reasonable bearing on determination”, check this box.
If “No i nformation available because:” check this box and note why (i.e. “found subject
with no reporting party or others present”, “unable to contact any known associates or
family”, etc.)
History Provided By (Name, Address, Phone Number, Relation): Document only known
family or intimate associates of the subject for hi story of behavioral health. This provides
medical facilities with two pieces of information: (1) Evaluation staff is able to obtain
relevant medical and behavioral health information for treatment, (2) Upon release from
a designated facility, these persons can be contacted to prevent the subject being released
onto the street.
Based upon the above information, there is probable cause to believe that said
person is, as a result of mental health disorder : (DTS, DTO, GDA (Adult), GDM
(Minor).
*Check all that apply. Be sure to circl e “Himself” or “Herself” based on the determination
or disclosure of the subject .
In the large signature box : Sign your name (John Doe), “Police Officer”, Badge number
Date: Write the date detained
Time: Write the time detained (not the time you arrived at the hospital)
Phone: Garden Grove Police Department Dispatch ( 714-741-5704 )
Name of Law Enforcement Agency or Evaluation Facility/Person: “Garden Grove Police
Department”
Address of Law Enforcement Agency or Evaluation Facility/Person:
11301 Acacia Parkway
Garden Grove