The certificate shall be in writing, executed under oath, and shall include the following information: (a) the name and address, if known, of the respondent; (b) the name and address, if known, of the respondent’s spouse, legal counsel, conservator or guardian, and next-of-kin; (c) the name and address, if known, of anyone currently providing psychiatric care to the respondent;
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(d) the names and addresses, if known, of other persons with knowledge of the respondent’s mental illness who may be called as witnesses at the assisted treatment hearing; (e) the name and work address of the certifying psychiatrist or other physician; (f) the name and address of the facility in which the respondent is undergoing emergency treatment/observation; (g) the certifying psychiatrist or other physician’s statement that he or she has examined the respondent since the respondent was placed in emergency treatment/observation; and (h) the certifying psychiatrist or other physician’s statement that, in his or her clinical opinion, the respondent is a danger to himself, herself or to others, or gravely disabled, and the clinical basis for this opinion.