VISITORS' REQUEST AND AUTHORIZATION FORM

Department of Mental Health Patton State Hospital

PSH 7383, Revised 7/10

VISITORS’ REQUEST AND AUTHORIZATION FORM

PLEASE READ CAREFULLY. Please PRINT or TYPE. The information requested will be used by officials of the Department of Mental Health (DMH) to

determine whether your questionnaire will be approved or disapproved. The information provided will be maintained in a file pertaining to the Individual.

In accordance with the Privacy Act of 1974 (PL93-579), providing your Social Security number is optional. However, any omission or falsification on this

questionnaire may be cause for denial of visiting. Please mail this form directly to the visiting office of the Hospital where the Individual is housed.

1. NAME OF INDIVIDUAL YOU WANT TO VISIT (LAST FIRST MIDDLE) INDIVIDUAL'S PATTON STATE HOSPITAL NUMBER

2. YOUR NAME (Print your name exactly as indicated on the photo identification you will be using) SUFFIX (Jr., Sr., etc.) HOME TELEPHONE NUMBER

3. MAIDEN NAME (If applicable) HAVE YOU EVER USED ANOTHER NAME? IF SO, PLEASE LIST RELATIONSHIP TO INDIVIDUAL: (Spouse, Son/Daughter, other)

4. DATE OF BIRTH (Mo/Day/Yr)

GE GENDER (Check one)

❑ MALE ❑ FEMALE

BIRTHPLACE (Cit

Count

State Country)

5. ID NUMBER ID TYPE (Check one):

❑ DRIVER'S LICENSE ❑ STATE ID ❑ MILITARY ID ❑ USINS CARD ❑ MCAS ❑ PASSPORT

OFFICIAL USE ONLY

EXPIRATION DATE:

ISSUED BY (County State Country) 6. SOCIAL SECURITY NUMBER

7. CURRENT RESIDENCE ADDRESS: STREET ADDRESS Apt. # (If Applicable) CITY STATE ZIP CODE

8. MAILING ADDRESS: (If different from Residence Address) CITY STATE ZIP CODE

9. PREVIOUS ADDRESS WITHIN PAST TWO YEARS: Apt. # (If Applicable) CITY STATE ZIP CODE

10. HAVE YOU EVER VISITED ANOTHER INDIVIDUAL(S) IN A CALIFORNIA STATE HOSPITAL? (Check one) ❑ YES ❑ NO

If YES, complete Item 10A. Attach additional sheet(s) if more than two Individuals.

10A. INDIVIDUAL NAME

PATTON STATE HOSP. # STATE HOSPITAL WHERE YOU VISITED

THE INDIVIDUAL

RELATIONSHIP TO INDIVIDUAL

11. HAVE YOU EVER BEEN DETAINED, ARRESTED, OR CONVICTED OF A CRIME? (Check one) ❑ YES ❑ NO

If YES, complete Item 11A. List all detentions, arrest and/or convictions. Failure to list all requested information may result in denial of visiting. Attach additional sheet(s) if necessary

11A. OFFENSE

PPROX. DATE DISPOSITION: (Dismissed, Probation, Jail, Prison) COUNTY STA

12. ARE YOU ON PROBATION?

(Check one) ❑ YES ❑ NO

If YES, answer 12A.

ARE YOU ON PAROLE OR CIVIL

ADDICT OUTPATIENT STATUS?

(Check one) ❑ YES ❑ NO

If YES, answer 12A.

HAVE YOU BEEN INCARCERATED IN A STATE

ADULT/JUVENILE CORRECTIONAL FACILITY?

(Check one) ❑ YES ❑ NO

I f YES, read 12B

13. ARE YOU CURRENTLY UNDER ANY TYPE OF

COURT IMPOSED PROGRAM? (Check one) ❑ YES

❑ NO

If YES, please explain on additional sheet and attach to this form.

12A. TYPE: (Court, Formal,

Informal, etc.)

SUPERVISING AGENCY NAME, ADDRESS, AND TELEPHONE NUMBER OF YOUR PROBATION/PAROLE

OFFICER:

COUNTY STA

12B. If you were discharged from an institution or discharged from parole or outpatient status within the last twelve (12) months, you must have prior written approval of the Executive

Director before visiting will be permitted. You will also need to provide a copy of your discharge paperwork.

CONTINUED ON BACK PAGE

Department of Mental Health Patton State Hospital

PSH 7383, Revised 7/10

14. If you are under 18 years of age and are not an emancipated minor or the Individual's legal spouse, you may only visit when accompanied by an approved

adult escort and when there is a completed Minor Visitation Request form (PSH 7144) on file. This approval is made through the Wellness & Recovery

Team (WRT) of the Individual you are requesting to visit. Contact the Individual’s Social Worker for access to the form and WRT approval.

15. VISITORS WITH DISABILITIES: If you have special requirements related to your disability (medical implants, prosthetic devices or requiring mobility

assistive devices, i.e., crutches, walkers, braces, wheelchairs, battery operated or custom prescribed wheelchairs, guide dog for the visually or hearing

impaired, insulin kit with syringes, etc.) you will need to attach a verifying statement from your physician to this application. Visitors with guide dogs will need

to provide the dog's certification paperwork upon visit check-in. Patton State Hospital will make every effort to provide reasonable accommodations for all

qualified/eligible visitors with disabilities in keeping with the safety and security of the Hospital and the public. If you have any questions and/or concerns,

please contact the Patton State Hospital Watch Commander for the Hospital Police Department/California Department of Corrections and Rehabilitation.

16. The following laws relate to visitation:

SUBJECT TO SEARCH: Visitors entering the hospital Visiting Center or hospital grounds are subject to a search of their person, vehicle and property.

Except as described below, visitors may leave the hospital rather than submit to a search of their person, vehicle or property. Refusal to submit to the search

will result in denial of visiting for that day.

Visitors may not elect to leave the hospital rather than submit to a search when institution officials possess a court issued search warrant or cause for a

search arises while the visitor is on the hospital grounds and the cause for the search is believed by hospital officials to be a criminal offense.

FIREARMS AND DRUGS ON HOSPITAL GROUNDS /ASSISTING INDIVIDUALS TO ESCAPE: It is a felony for anyone to assist Individuals to

escape. Bringing firearms, deadly weapons, explosives, tear gas, drugs, drug paraphernalia, or selling drugs on prison grounds, or giving/selling Individuals

firearms, weapons, explosives, liquor, cocaine, or other narcotics or any kind of drugs, including marijuana, is a crime (Sections 2772, 2790, 4534, 4535, 4550,

4573, 4573.5, 4573.6. 4573.8, 4573.9, 4574, 4600, California Penal Code).

NO ITEMS (e.g. money, packages, gifts, property, etc.) WILL BE ACCEPTED OR EXCHANGED BETWEEN VISITORS AND

INDIVIDUALS SERVED WHILE IN THE VISITING CENTER: (Section 4570, 4570.1, California Penal Code).

FALSE IDENTIFICATION: Anyone who falsely identifies himself/herself to gain admittance is guilty of a misdemeanor. (Section 4570.5, 4571

California Penal Code).

TRESPASSING: Entry on institution property for unauthorized purposes will be considered trespassing as provided in Section 602(j) of the California

Penal Code. Refusal or failure to leave the property when requested to do so by an official will be considered trespassing as provided in Section 602(p) of the

California Penal Code.

PERIOD OF EMERGENCY: In the event of an emergency situation that affects a significant portion of the Individual population at the hospital, the

visiting program and other program activities may be suspended during the period of emergency (Section 2601(d), California Penal Code).

HOSTAGES: Hostages will not be recognized for bargaining purposes during attempted escapes by Individuals (Section 3304, California Code of

Regulations, Title 15, Division 3, Chapter I).

17. If you are APPROVED to visit, the Hospital Police Department will notify you by mail and the Individual you are requesting to visit will also be notified.

If you are DISAPPROVED to visit, the Hospital Police Department will notify you by mail. Prior to completion of the approval all visits will be “NO

Contact” type visits.

VERIFICATION OF MAILING I have read and understand the above information and agree to follow

all Federal, State and Patton State Hospital rules and regulations.

I have mailed this Visiting Questionnaire to the visitor applicant.

VISITOR SIGNATURE DATE INDIVIDUAL SIGNATURE / PATTON # DATE

OFFICIAL USE ONLY-TO BE COMPLETED BY PATTON STATE HOSPITAL STAFF

Criminal History:  NO  YES CII/FBI # ________________________

❑ APPROVED (notification will not be made)

❑ DISAPPROVED, for the following reason(s): (If

DISAPPROVED, the applicant and Individual are to be informed in writing of the disapproval.)

 Omissions and/or falsifications Section(s): ______________________________  Need copy

of Declaration of Discharge

 Need disposition(s) for:

 Applicant is under:  parole  formal probation  Civil Addict Outpatient supervision

 Arrest record received via DOI indicates applicant

has an extensive and /or recent history of criminal activity for offenses that are

particularly sensitive to the institutional security. May reapply after: (DATE: _____________________)

 Other: ______________________________________________________________________________________________________

 Applicant's privileges to visit will be reconsidered:

 upon receipt of the above requested information and/or  after (DATE: _____________________ )

PRINT NAME SIGNATURE PATTON STATE HOSPTIAL TITLE DATE

Notification will only be made to those visitors who are receiving an adverse visitor application status (re: Denials and Terminations).

❑ INDIVIDUAL NOTIFIED ON THIS DATE: _________________________ BY WHOM: ____________________________

❑ VISITOR WAS NOTIFIED ON THIS DATE: _________________________ BY WHOM: ____________________________

Attach a copy of your photo identification and mail this application to the Patton State Hospital,

Hospital Police Department, 3102 East Highland Avenue, Patton CA 92369.