placed in restraints;
placed in seclusion;
restricted from mail communication;
restricted from telephone communication;
restricted from visitation;
other:
I certify that I delivered in person a copy of this notice to the recipient and the facility director. Mailed a copy of this notice to each of the following entitled to receive notice, unless otherwise specified, by the recipient as follows:
Guardian
Representative Guardianship & Advocacy Comm.
Designed by Recipient
Affected Party