The request for admission to psychiatric care provided for in article L. 3212-1 must include the following handwritten information:
1° The wording of the request for admission to psychiatric care;
2° The surname, first names, date of birth and place of residence of the person requesting care and of the person for whom care is requested;
3° Where applicable, their degree of kinship or the nature of the relationship existing between them prior to the request for care;
4° The date;
5° The signature.
If the person requesting care cannot write or is unable to write, the request is received by the mayor, the police commissioner or the director of the establishment, who acknowledges it.

