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IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: PROBABLE CAUSE FOR INVOLUNTARY HOSPITALIZATION FOR EXAMINATION West Virginia Resident [W.Va. Code: §27-5-2(f)] This matter was heard on the _______ __ day of ____________________________, 20_________. The Applicant in this cause, _________________________________________, appeared in person [ Check Appropriate Items ] __ pro se, or __ was represented by ___________________________________________, Assistant/Pr osecuting Attorney of ______________________________ County, West Virginia; The Respondent appeared in person and by appointed counsel _____________________________ _________; Testimony was also presented by, _______________________________________________________________________________, Physician/Psychologist/Court approv ed Licensed Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification, and also by the following witnesses: _______________________________________________________________________________ ____________________________________________________________________________________________________________ . After hearing the testimony of witnesses and receiving all relevant evidence, and upon examination of the written report and certification of the Examiner; Upon the arguments of counsel for the parties, the Court makes the following FINDINGS [ Initial Appropriate Items ] : The Respondent _________IS _________IS NOT a resident of ___________________________ County, West Virginia. The Respondent _________WAS _________WAS NOT found in ___________________________ County, West Virginia. The Court further FINDS that there is [ Initial Appropriate Items ]: __________ PROBAB LE CAUSE __________ NO PR OBABLE CAUSE to believe the Respondent is addicted. __________ PROBAB LE CAUSE __________ NO PROBABLE CAUSE to believe the Respondent is mentally ill. The Court further FINDS probable ca use to believe that the Respondent [ initial one ] __________IS __________ IS NOT likely to cause serious harm to him/her self and/or others becaus e of such mental illness or addiction if allowed to remain at liberty. SCA-MH 906R-1 / 6-06 § 27-5-2 INVOLUNTARY HOSPITALIZATION ORDER - Page 1 of 2 The specific facts upon which these findings of probable cause are based are as follows: ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ______________________________________________________________________________________________________ Accordingly, it is hereby ORDERED: 1. That the Respondent, ______________________________________________, be committed to the custody of the Secretary of the Department of Health and Human Resources for initial placemen t at _________________________________________ _____________ ____________________________________________________________ _______ mental health facility; and 2. That the Respondent be further examined and/ or treated as required under the provisions of West Virginia Code : § 27-5-3. And further, if applicable [Initial if applicable] ___________ It is ORDERED pursuant to West Virginia Code : § 27-5-3(g) that the Respondent shall be involuntarily hospitalized for addiction only until detoxification is accomplished. And further, if applicable [Initial if applicable] ___________ It is recommended that the Respondent be closely monitored for possible medical complications pursuant to West Virginia Code : § 27-5-2(i). The Respondent is hereby remanded to th e custody of the Sheriff of this County who shall transport the Respondent to the mental health facility as required by law. The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit three attested copies thereof to the Sheriff of this County, one for delivery with the Respondent to th e mental health facility. The Clerk shall also transmit attested copies to counsel of record, to the Applicant, and to the ______________________________________________________ Mental Health Center. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE SCA-MH 906R-2 / 6-06 § 27-5-2 INVOLUNTARY HOSPITALIZATION ORDER - Page 2 of 2