Fill and Sign the Chapter 25 031 Commitment Procedures the Form

PETITION FOR INVOLUNTARY COMMITMENT NORTH DAKOTA SUPREME COURT SFN 17260 (GN -1) (Rev. 08-2015 ) CASE NO. __________________ IN THE INTEREST OF Name of Respondent: Information about the respondent is as follow : Address: City: State: Zip Code: Telephone: The respondent's present whereabouts are as follow: Age: Date of birth (year) : Social Security # (last four) : For full date of birth and Social Security Number - use Form GN -1A - Confidential Information Form Gender: Male Female Marital Status: Occupation: Name of employer: Approximate monthly earnings: List the name, address, and relationship of respondent's relative or guardian, or, if none, a friend of the respondent: Name: Relationship: Telephone: Address: City: State: Zip Code: Name of attorney who most recently represented the respondent: Address: City: State: Zip Code: Petitioner's relationship to respondent: Date of most recent filin g of petition for involuntary commitment of respondent: County in which petition was filed: Petition was granted. dismissed . PETITION The petitioner comes before the court and respectfully alleges: 1. That the petitioner is 18 years of age or o lder. 2. That the respondent presently resides in the below named county in the State of North Dakota. County where respondent resides: N.D.C.C. 25 -03.1 -08 STATE OF NORTH DAKOTA County of North Dakota Supreme Court SFN 17260 (GN -1) (Rev. 08-2015 ) Page 2 3. That the petitio ner believes that the respondent is mentally ill and as a result of such condition there is a reasonable expectation of a serious risk of harm if respondent is n ot treated. chemically dependent and as a result of such condition there is a reasonable ex pectation of a serious risk of harm if respondent is not treated. 4. That because of the foregoing condition, the respondent requires treatment. 5. That the assertions contained in paragraph 3 are based upon the following specific facts (attach additiona l sheets, if necessary): 6. That the names, addresses, and telephone numbers of witnesses who will verify these facts are as follows: Name: Telephone: Address: City: State: Zip Code: Name: Telephone: Address: City: State: Zip Co de: 7. That petitioner believes that is is not necessary to take the respondent into immediate custody and emergency treatment. [Immediate custody should be requested only if the respondent is seriously mentally impaired or chemically dependent and is imminently likely to injure the respondent or other persons if allowed to remain at liberty.] 8. [Complete only if immediate custody and emergency treatment requested.] Overt act(s) of the respondent which indicate the res pondent is likely to inju re themself or other persons if allowed to remain at liberty are described as follows: 9. That to the petitioner's best knowledge The respondent is indigent. The respondent is not indigent. The petitioner believes that an evaluat ion of the respondent's condition should be made and involuntary commitment and treatment is required. Signature of petitioner: Date: Telephone: Address: City: State: Zip Code: North Dakota Supreme Court SFN 17260 (GN -1) (Rev. 08-2015 ) Page 3 State of North Dakota ) ) ss. County of ________________________) The undersigned, being first sworn, on their oath states that the undersigned is the petitioner in the above matter, and that the facts in this petition are true to the affiant's best information and belief X___________________________________________________________ Petitioner Dated this ________ day of ____________________ of ________, before me personally appeared __________________________________ _________ ___ ______________________________________________ who having been sworn state that to the best of their knowledge and belief the statements in this petition are true. X___________________________________________________________ Notary Public (Seal) My commission expires __________________________________________ APPROVAL OF ATTORNEY This petition was reviewed for probable cause and I approve the filing of the petition. Dated this ________ day of __________________ of ________. X________ ______________________________________________________ Attorney _______________________________________________________________ County