California Welfare and Institutions Code Section 6253

In the Superior Court of the State of California for the County of ________

The People

For the Best Interest and Protection of

,

⎫⎪⎪⎪

Certificate of Medical Examiners

as a and

⎬

⎪

Concerning ,

⎪

and ,

⎪

_____ Respondents

⎪⎭

We, Dr. ________ and Dr. ________, medical examiners in the County of ________, duly appointed and certified as such, do hereby certify under our hands that we have examined ________, alleged to be a ________, and have attended before a judge of said court at the hearing on the petition concerning said person, and have heard the testimony of all witnesses, and, as a result of the examination, have testified under oath before the court to the following facts concerning the alleged ____________:

Name  

Address  

Age Sex  

Occupation Marital status  

(Single, married, widowed, divorced) 

Religious belief  

Pertinent case history  

General physical condition  

Present mental status  

Laboratory reports (if any)   

Tentative diagnosis of mental health  

Recommendation for disposition or supervision, treatment and care  

Reason for the recommendation  

Date ________________

_____ _____ Medical Examiner

_____ _____ Medical Examiner