The report of a patient’s property required by Section 5210 to be made by the person taking him into custody for evaluation shall be in substantially the following form:

Report of Officer

I hereby report to the Superior Court for the County of _____ that the personal property of the person apprehended, described generally as ____ was preserved and safeguarded by ____ (Insert name of person taking him into custody, responsible relative, guardian, or conservator).

That property is now located at ____.