(1) A mental health professional who, upon evaluation of a person admitted for emergency protective custody under section 71-919, determines that such person is mentally ill and dangerous shall execute a written certificate as provided in subsection (2) of this section not later than twenty-four hours after the completion of such evaluation. A copy of such certificate shall be immediately forwarded to the county attorney.
(2) The certificate shall be in writing and shall include the following information:
(a) The subject's name and address, if known;
(b) The name and address of the subject's spouse, legal counsel, guardian or conservator, and next-of-kin, if known;
(c) The name and address of anyone providing psychiatric or other care or treatment to the subject, if known;
(d) The name and address of any other person who may have knowledge of the subject's mental illness or substance dependence who may be called as a witness at a mental health board hearing with respect to the subject, if known;
(e) The name and address of the medical facility in which the subject is being held for emergency protective custody and evaluation;
(f) The name and work address of the certifying mental health professional;
(g) A statement by the certifying mental health professional that he or she has evaluated the subject since the subject was admitted for emergency protective custody and evaluation; and
(h) A statement by the certifying mental health professional that, in his or her clinical opinion, the subject is mentally ill and dangerous and the clinical basis for such opinion.