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IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI COMPLAINANT VS CAUSE NO. , RESPONDENT Chancery Clerk, County Rec. In P . COMPLAINT FOR COMMITTAL COMES NOW , Plaintiff and files this his/her Complaint to commit , Defendant, to a private treatment facility for treatment of chemical dependency, and in support thereof would show: 1. Respondent is a ( ) year old , and may be found at this time in County, Mississippi, at , , Mississippi ( ) -     . 2. Complainant , , , , telephone ( ) - , is the of the Respondent and is genuinely interested in Respondent's welfare. 3. Respondent is a drug addict, i.e., Respondent is powerless over drugs and Respondent's life has thereby become unmanageable. Respondent is addicted to . 4. Respondent's mental and physical health, continued family life and position in the community are dependent on Respondent's treatment at a private treatment facility providing treatment for chemically dependent persons. 5. Respondent has refused to commit himself/herself to such private treatment facility, though having been requested so to do by persons who genuinely care for Respondent's well-being. 6. Complainant has selected to treat Respondent at , , , MS . Said facility is a private treatment facility, approved by the Department of Mental Health, Division of Alcohol and Drug Abuse of the State of Mississippi, 7. Complainant has made adequate financial arrangements for Respondent's treatment at such facility. 8. Such treatment facility has approved the admission of Respondent, subject to commitment by this Court.9. The Respondent is under the conscious influence of the need for drugs to the extent that if Respondent is served with process, Respondent will, in all likelihood, flee the jurisdiction of the Court or physically harm himself/herself or others, and Respondent should be committed and confined, without notice, until a hearing, to such private treatment facility, to include primary and extended care and to include psychiatric care and medication, if needed and prescribed and ordered by the medical director of the facility, and that such private treatment facility be ordered to release information to Plaintiff's attorney as to whether Respondent has executed a Waiver in this cause. WHEREFORE, PREMISES CONSIDERED, Complainant prays that Respondent be committed to such treatment facility for treatment for chemical dependency until released by authorized personnel at such treatment facility. Complainant prays for general relief. Respectfully submitted this day of       , 20 _______________________________________ Attorney for STATE OF MISSISSIPPI COUNTY OF THIS DAY PERSONALLY appeared before me, the undersigned Notary Public in and for the jurisdiction aforesaid, , who after having been by me first duly sworn, on oath depose and say that he/she is the Complainant, and that all the matters and things stated in the above and foregoing Complaint are true and correct as therein stated. _________________________________ SWORN TO AND subscribed before me this the day of , . CHANCERY CLERK BY _______________________________________ D.C. _________________________________________ NOTARY PUBLIC My Commission Expires Of counsel: Telephone: MSB # Attorney for