Fill and Sign the In the Matter of the Hospitalization of Form

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Hospitalization of: ) ) ) , ) Respondent. ) ) Case No. Date of Birth: ) ) APPLICATION FOR 48-HOUR EMERGENCY COMMITMENT 1. I hereby apply to the administrator of an approved public treatment facility for emergency commitment of the respondent named above pursuant to AS 47.37.180. 2. I am the certifying physician, physician assi stant, or advanced nurse practitioner the respondent’s spouse the respondent’s guardian the respondent’s relative a responsible person 3. Respondent is an intoxicated person (defined as a person whose mental or physical functioning is substantially impaired as a result of the use of alcohol or drugs) who: has threatened, attempted to inflict, or inflicted physical harm on another or is likely to inflict physical harm on another unless committed. is incapacitated by alcohol or drugs. 4. The facts that support the need for emergency treatment are as follows: Page 1 of 2 MC-600 (5/10)(cs) Page 2 of 2 MC-600 (5/10)(cs) APPLICATION FOR 48-HOUR EMERGENCY COMMITMENT AS 47.37.180 5. A Certificate of Need for Emergency / Involuntary Commitment prepared within the past two days by a physician, physician’s assistant, or advanced nurse practitioner, accompanies this application. Date Signature of Applicant Type or Print Name The Application for 48-Hour Emergency Commitment , and accompanying Certificate of Need for Emergency / Involuntary Commitment provide sufficient grounds for commitment and the application is approved. fail to sustain the grounds for commitment and the application is refused. Dated this day of , 20 , at am. p.m. Administrator Type or Print Name Name of Public Treatment Facility