1. A. Application for admission for voluntary treatment according to A.R.S. § 36-518 shall be made to a mental health agency on AHCCCS form MH-210, Titled “Application for Voluntary Treatment,” in Exhibit I, by any individual who:

   1. 1. Voluntarily makes application as provided in subsection (A);
   2. 2. Gives informed consent;
   3. 3. Has not been adjudicated as an incapacitated person according to A.R.S. Title 14, Chapter 5, or Title 36, Chapter 5; and
   4. 4. If a minor, is appropriately admitted according to A.R.S. § 36-518.

2. B. Any mental health agency that is not a health plan under R9-21-501 and that receives an application for voluntary treatment by a client shall immediately refer the client to the appropriate health plan for treatment as provided under this Section, except that in the case of an emergency, a mental health treatment agency licensed by the Department to provide treatment under A.R.S. § 36-518 may accept an application for voluntary treatment and admit the client for treatment as follows:

   1. 1. Prior to admission of a client under this Section, the agency shall notify the appropriate health plan of the potential admission and treatment so that the health plan may first:

      1. a. Provide other services or treatment to the client as an alternative; or
      2. b. Authorize treatment of the client.
   2. 2. If the agency does not provide notice according to subsection (B)(1), the health plan shall not be obligated to pay for the treatment provided.

3. C. Any mental health agency providing treatment according to A.R.S. § 36-518 shall place in the medical record of the individual to be treated the following:

   1. 1. A completed copy of the application for voluntary treatment;
   2. 2. A completed informed consent form according to R9-21-511; and
   3. 3. A written statement of the individual’s present mental condition.
4. D. If the client admitted under this rule does not have an ISP, the health plan shall prepare one in accordance with Article 3 of this Chapter. If the client already has an ISP, the health plan shall commence a review of the ISP as provided in R9-21-313 and, if necessary, take steps to modify the ISP in accordance with R9-21-314.
5. 1. Withdraw or modify my consent to treatment at any time.
6. 2. Receive a booklet explaining my rights under Arizona law and assistance from a human rights advocate if I desire.
7. 3. A fair explanation of the treatment I am to receive and the purposes of that treatment.
8. 4. A description of any material and substantial risk reasonably to be expected as a result of the treatment.
9. 5. An answer to my inquiries concerning treatment.
10. 6. Revoke my consent to treatment at any time.

11. 7. Discharge within 24 hours of my written request (excluding weekends and holidays) unless the medical director of the treatment agency files a petition for court-ordered treatment.

    ___________________________________________________

    Person’s Signature

    ___________________________________________________

    Date

    ADHS/BHS Form MH-210 (9/93)

Exhibit I. Application for Voluntary Treatment

APPLICATION FOR VOLUNTARY TREATMENT

(Pursuant to A.R.S. § 36-518)

I, ______________________________________________________________________________________, hereby request that the

(Person’s Name)

__________________________________________________________place me in a program or agency for mental health treatment.

(Mental Health Agency)

I understand that my capacity to give informed consent to treatment will be determined before I am allowed to voluntarily consent to treatment. My informed consent to treatment will be given on a separate form.

Further, I am aware that I am entitled to:

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit I repealed, new Exhibit I adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Renumbered from a position after R9-21-510 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).

Historical Note

Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Amended under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3). Former Section R9-21-509 renumbered to R9-21-508; new Section R9-21-509 renumbered from R9-21-510 and amended by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2). Amended by final rulemaking at 29 A.A.R. 898 (April 21, 2023), effective May 30, 2023 (Supp. 23-1).