Mental Health Premise Alert Form

The purpose of the Mental Health Premise Alert Form is to provide responding law enforcement officers and other first responders with information which may assist them in their investigations and responses to calls for service.

Completing this form is voluntary. The information provided may be submitted and added to law enforcement dispatch systems. This form can be completed by:

• Individuals who have a mental illness
• Parents or guardians of minor children who have a mental illness
• Those with legal guardianship for another who has a mental illness*
• Those with lawful power of attorney for another who has a mental illness*
• Current foster care parents of child living within premise who has a mental illness (the child’s name is not required)
• A family member living at the premise of a person who has mental illness

Information provided in the Mental Health Premise Alert Voluntary Early Notification Registration Form will be kept as a hard copy paper document by the Johnson County Sheriff’s Office, and will be maintained in the Johnson County Sheriff’s Office Computer Aided Dispatch.

When dispatch receives a call about the address listed on the form, the information on the form may be provided to the responding law enforcement officers/and or other emergency responders by radio to assist them in their investigations and responses to calls for service. The information will be maintained by the Sheriff’s Office for three months. At the end of three months, the Sheriff’s Office will contact the provider of the information to confirm its accuracy and consent to continue to keep the information. In the event the provider of the information wants to change or remove this form before the three-month period ends, they must contact the Sheriff’s Office at 913-782-0720.