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Petition for Initial D etention (PTINDT) - Page 1 of 4 MP 401 ( 07 /201 9) RCW 71.05.150, 71.05.153 Superior Court of Washington County of In re the Detention of: _ Respondent Case No. Petition for Initial Detention (PTINDT) [ ] Mental Health [ ] Substance Use Pursuant to chapter [ ] 71.05 RCW [ ] 71.34 RCW , Petitioner, a Designated Crisis Responder designated by ______________________________ County, alleges under penalty of perjury that the Respondent; as the result of (check all that apply): [ ] a mental disorder [ ] substance use disorder: [ ] Presents an immine nt likelihood of serious harm : [ ] to self [ ] to others [ ] to property [ ] Is in imminent danger because of being gravely disabled : [ ] Is in danger of serious physical harm resulting from a failure to provide for his or her essential human needs of health or safety . [ ] Manifests severe deterioration in routin e functioning evidenced by repeated and escalating loss of cognitive or volitional control over his or her actions and is not receiving such care as is essential for his or her health or safety. The Respondent was brought to my attention under the following circumstances: Petition for Initial D etention (PTINDT) - Page 2 of 4 MP 401 ( 07 /201 9) RCW 71.05.150, 71.05.153 Based on my personal observation and/or information obtained from reliable people and/or investigation of the specific facts alleged, and/or followi ng a face -to -face interview with the Respondent, the facts that led me to conclude that the Respondent suffers from a mental disorder or substance use disorder are as follows: The facts that led me to conclude that the Respondent presents a likelihood of serious harm and/or is gravely disabled are as follows: No alternative less than detention, including voluntary hospitalization, is clinically appropriate, necessary, and in the best interest of the R espondent or others because: Petition for Initial D etention (PTINDT) - Page 3 of 4 MP 401 ( 07 /201 9) RCW 71.05.150, 71.05.153 Consultation with the ER doctor regarding their observations and opinions: Therefore the Petitioner requests that the Respondent be detained at a (n): [ ] evaluation and treatment facilit y [ ] secure withdrawal management and stabilization facility [ ] approved substance use disorder treatment program for no more than 72 hours (excluding Saturdays, Sundays , and legal holidays) for evaluation and treatment pursuant to ch. 71.05 RCW . I certify under penalty of perjury under the laws of the state of Washington that the foregoing is true and correct. Signed at (City/Town): (State): on (Date): . Petitioner Print Name Name of Agency Declaration from Witness (AFW) - Page 4 of 4 MP 401 ( 07 /2019 ) RCW 71.05.150, 71.05.153 Superior Court of Washington Coun ty of In re the Detention of: _ Respondent Case No. Declaration from Witness (AFW) (Optional use) I declare the following: I am willing to testify to the above facts in any subsequent judicial proceedings. I dec lare under penalty of perjury, under the laws of the state of Washington, that the foregoing is true and correct. Signed at (City/Town): (State): on (Date): . Petitioner Print Name Witness Name of Agency