Fill and Sign the At Supplemental Hearing Form

Name And Address Of Petitioner Name And Address Of Treatment Center Or Physician 3. 6. 5. 4. 2. You have been committed as a substance abuser, and it has b een alleged that you need to be held in a 24-hour facility for longer than forty-five (45) consecutive days. It has been alleged that you have clearly refused to compl y with the treatment prescribed for you under an outpatient commitment order. You have been committed after being charged with a viol ent crime and were found not guilty by reason of insanity or incapable of proceeding. The physician now treating yo u has determined that you do not need further treatment, but you may not be released without a hearing. It has been alleged that you intend to move to another county within the State of North Carolina and are in need of further treatment at your new residence. 1. STATE OF NORTH CAROLINA File No. (Over) In The General Court Of Justice District Court Division County IN THE MATTER OF: ORDER TO APPEAR AT SUPPLEMENTAL HEARING FOR INVOLUNTARY COMMITMENT G.S. 122C-274, -277, -290, -291 AOC-SP-205, Rev. 7/04 You are ORDERED to appear before a district court judg e at the date, time and location indicated below. At that hearing, it will be determined whether your commitment will be continued or modified, or whether you will be discharg ed. 2004 Administrative Office of the Courts Location of Hearing NOTE TO CLERK: In addition to service on the respondent, this ORDER must be mailed to the petitioner (unless the pet itioner waived his/her right to notice), the designated treatment center or physician and the respondent's counsel, if any, by first- class mail at least seventy-two (72) hours before the hearing. (If respondent was committed as a substance abuser, counsel appointed at the initial hearing r emains responsible for representation.) Date Of Hearing Signature AM PM Time Of Hearing Assistant CSC Clerk Of Superior Court TO PETITIONER-ATTORNEY-TREATMENT CENTER This ORDER to the respondent is sent to you to give you no tice of the hearing described above. At the hearing you will be allowed to present evidence. You may hire an attorney to represent you. If you cannot afford to hire an attorney and have been committed as a substance ab user, an attorney will be appointed for you. If you have been committed to outpatient commitment, you may ask the judge to appoint an attorney for you. Based on the facts in the particular case, the judge may appoint one for you. You have requested a hearing to determine whether you should be discharged. The physician now treating you at the inpatient facility where you are being held has determined that you meet the criteria for outpatient commitment. You are now under a commitment order. Name And Address Of Respondent ORDER TO RESPONDENT NAMED ABOVE Name And Address Of Attorney For Respondent Date RETURN OF SERVICE NOTICE TO SHERIFF CLERK'S CERTIFICATION OF SERVICE Clerk Of Superior Court Assistant CSC petitioner treatment center/physician respondent's attorney By delivering to the respondent named above a copy of this Order. Respondent WAS NOT served for the following reason: AOC-SP-205, Side Two, Rev. 7/042004 Administrative Office of the Courts This Notice must be served on the respondent personally at least seventy-two (72) hours before the hearing. I certify that this Order was received and served on the respondent as follows: Name Of Respondent Date Received Date Returned Signature Of Deputy Sheriff Making Return I certify that I have mailed a copy of this Order to the following, whose names and addresses are shown on the fro nt of this form: Signature Deputy CSC Date Served Time Served AM PM Date County Of Sheriff Name Of Deputy Sheriff Making Return (Type Or Print)