Fill and Sign the Involuntary Commitment Unc School of Government Form

Name And Address Of Respondent STATE OF NORTH CAROLINA File No. Drivers License No. Of Respondent State Date Of Birth Social Security No. Of Respondent Deputy CSC Magistrate and take the respondent for examination by a person authorized by law to conduct the examination. (A COPY OF THE EXAMINER'S FINDINGS SHALL BE TRANSMITTED TO THE CLERK OF SUPERIOR COURT IMMEDIATELY .) IF the examiner finds that the respondent IS NOT a proper subject for involuntary commitment, then you shall take the respondent home or to a consenting person's home in the originating county and release him/her. IF the examiner finds that the respondent IS mentally ill and a pro per subject for outpatient commitment, then you shall take the respondent home or to a consenting person's home in the originating county and release him/her. IF the examiner finds that the respondent IS mentally ill and a pro per subject for inpatient commitment, then you shall transport the respondent to the 24-hour facility named below for temporary custody, e xamination and treatment pending a district court hearing. IF the examiner finds that the respondent IS a substance abuser and subject to involuntary commitment, the examiner must recommend whether the respondent be taken to a 24-hour facility or re leased, and then you shall either release him/her or transport the respondent to the 24-hour facility named below for te mporary custody, examination and treatment pending a district court hearing. 1. CUSTODY ORDER I. FINDINGS The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are true and that the respondent is probably: (Check all that apply) mentally ill and dangerous to self or others or mentally ill and in need o f treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. 1. In addition to being mentally ill, the respondent probably is also ment ally retarded. a substance abuser and dangerous to self or others. Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General (Over) In The General Court Of Justice District Court Division County IN THE MATTER OF: FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT G.S. 122C-261, -263, -281, -283 AOC-SP-302, Rev. 9/03 2003 Administrative Office of the Courts You shall take the respondent into custody within 24 hours after the date this Order is signed. Without unnecessary delay after assuming custody, you shall take the respondent to an area facility for examination by a person authorized by law to conduct the examinati on; if an authorized examiner is not immediately available in the area facility, you shall take the respondent to any authorized examiner locally avai lable. If an authorized examiner is not available, you may temporarily detain the respondent in an area facility if one is available; if an area facility is not available, you may detain the respondent under appropriate supervision, in the respondent's home, in a private hospital or clinic, or in a general hospit al, but not in a jail or other penal facility. Complete the Return Of Service on the reverse and return to the Clerk of Superior Court immediately. NOTE TO MAGISTRATE OR CLERK: If the respondent is mentally retarded in addition to being mentally ill, you must contact the area aut hority before issuing a custody order to determine the facility to which the respondent will be taken. If the area mental health authority where the r espondent resides has a single portal plan, you must call the area authority to determine the appropriate 24-hour facility or other treatment before issuing any custody or der. NOTE TO ANY LAW ENFORCEMENT OFFICER: The Court ORDERS you to take the above named respondent into custody TO ANY LAW ENFORCEMENT OFFICER: and transport the respondent directly to the 24-hour facility named below, for temporary custody, examination and treatment pending a district court hearing. (FOR PHYSICIAN/PSYCHOLOGIST PETITIONERS ONLY.) 2. 2. AM Signature PM Assistant CSC Clerk Of Superior Court Date Time Name Of 24-Hour Facility For Mentally Ill Or following facility designated by area authority: Name Of 24-Hour Facility For Substance Abuser Or following facility designated by area authority: Pursuant to G.S. 122C-261(f), I took custody of the respondent from the state 24-hour facility named above, where he/she was not admitted, and transported the respondent and placed him/her in the temporary custody of the facility named below for observation and treatment. I took custody of the respondent from the officer named a bove, transported the respondent and placed him/her in the temporary custody of the facility named below for observati on and treatment. I transported the respondent directly to and placed him/her in the temporary custody of the facility named below. The examiner's written statement is attached. will be forwarded. 3. 2. 1. Upon examination, the examiner named above found tha t the respondent is mentally ill and meets the criteria for outpatient commitment, or is a substance abuser and meets the criteria for commitment and the examiner recommends release pending a hearing. I returned the r espondent to his/her regular residence or the home of a consenting person. Upon examination, the examiner named above found tha t the respondent did not meet the criteria for inpatient or outpatient commitment. I returned the respondent to his/her regular residence or the home of a consenting pe rson. Upon examination, the examiner named above found tha t the respondent is mentally ill and meets the criteria for inpatient commitment, or is a substance abuser and meets t he criteria for commitment and the examiner recommends that the respondent be held pending the district court hearing. I transported the respondent and placed the respondent in the temporary custody of the facility named below for observation and treatment. I placed the respondent in the custody of the agency named below for transportation to the 24-hour facility. Respondent WAS NOT taken into custody for the following r eason: 2. 1. I certify that this Order was received and served as follows: A. FOR USE AFTER PRELIMINARY EXAMINATION Date Delivered The respondent was presented to an authorized examiner locally available as shown below. The respondent was temporarily detained at the facility named below until the respondent could be examined by an authorized examiner locally available. II. RETURN OF SERVICE Time PM AOC-SP-302, Side Two, Rev. 9/03, 2003 Administrative Office of the Courts AM D. FOR USE WHEN STATE FACILITY TRANSFERS WITHOUT ADMI SSION Signature Of Law Enforcement Or State Facility Official AM PM C. FOR USE WHEN ANOTHER AGENCY TRANSPORTS THE RESPON DENT Signature Of Law Enforcement Official AM PM B. FOR USE WHEN PETITIONER IS PHYSICIAN/PSYCHOLOGIST Signature Of Law Enforcement Official AM PM Signature Of Law Enforcement Official AM PM Date Respondent Taken Into Custody Time Date Presented AM PM Name Of Examiner Name Of Local Facility Name Of 24-Hour Facility Name Of Transporting Agency Date Delivered Time Delivered Date Of Return Date Delivered Time Delivered Date Of Return Name Of 24-Hour Facility Name Of Transporting Agency Date Delivered Time Delivered Date Of Return Name Of 24-Hour Facility Name Of Transporting Agency Name Of Facility To Which Transferred Name Of Transporting Agency Time Delivered Date Of Return