Involuntary Services Petition Form

INVOLUNTARY SERVICES PETITION FORM

Case Number:   Court or Agency:

Petitioner Name:   Relationship to Subject:

Respondent (Subject) Name:

Respondent Date of Birth:

RECITALS

WHEREAS, Petitioner asserts that Respondent is suffering from a mental, behavioral or related condition that presents a risk of harm to Respondent or others, or renders Respondent unable to provide for basic personal needs in a manner likely to result in serious physical harm absent intervention;

WHEREAS, Petitioner submits observed facts, clinical evaluations and other evidence supporting the need for involuntary services, and seeks an order authorizing appropriate involuntary services and related relief pursuant to applicable law and procedures;

WHEREAS, Petitioner requests the court or administrative tribunal to consider immediate and interim protective measures where necessary to prevent imminent harm and to establish a supervised care plan for Respondent;

NOW THEREFORE, Petitioner alleges the following and respectfully petitions the court or agency for the relief set forth below.

1. JURISDICTION AND PARTIES

1.1 Petitioner is an individual who has standing to file this petition based upon direct knowledge of the facts below and the relationship indicated above. Petitioner contact information is provided above for service and notice.

1.2 Respondent is the individual identified above and is believed to be subject to the court or agency's jurisdiction for purposes of this Petition.

2. GROUNDS FOR PETITION

Petitioner alleges one or more of the following grounds (check all that apply and provide factual support below):

Danger to self (suicidal behavior, self-harm)    Danger to others (threats, violent acts)    Grave disability (unable to provide for basic needs)

Date(s) of key incident(s):

3. MEDICAL AND CLINICAL INFORMATION

4. EVIDENCE AND WITNESSES

5. RELIEF REQUESTED

Petitioner requests that the court or agency enter orders as appropriate to the facts and law, including but not limited to the following (check and supplement):

Involuntary hospitalization or inpatient treatment
Authorization for involuntary medication where clinically indicated
Court-ordered outpatient commitment with specified treatment plan
Temporary conservatorship or protective placement authority
Mandated community-based services and case management
Other (describe below)

6. REQUEST FOR IMMEDIATE OR EMERGENCY ACTION

Petitioner requests an emergency protective hold or temporary detention for immediate evaluation

7. NOTICE

7.1 Petitioner requests that all notices, orders and other communications be sent to Petitioner at the contact information provided above, and to the following additional addresses as required by procedure.

8. FINDINGS REQUESTED AND LEGAL STANDARD

Petitioner requests that the court or agency make specific findings that: (a) Respondent meets the statutory and evidentiary standard for involuntary intervention; (b) less restrictive alternatives have been considered and are insufficient to prevent the risk of harm; and (c) the proposed involuntary services are necessary and proportionate to Respondent's needs. Petitioner submits that the applicable standard of proof for the requested orders is clear and convincing evidence and that the evidence contained in this petition satisfies that standard.

9. SERVICE PLAN, DURATION AND REVIEW

Petitioner requests periodic review of any involuntary order at intervals required by law and requests that the court require documented progress reports by the provider identified in the service plan.

10. CONFIDENTIALITY

All records, evaluations and disclosures produced in connection with this petition shall be handled in accordance with applicable confidentiality laws governing mental health, medical, and protected personal information. Petitioner requests any necessary protective orders to limit dissemination of sensitive records to authorized persons only.

11. MISCELLANEOUS PROVISIONS

Governing Law. This Petition shall be governed by the laws and procedures of the jurisdiction in which the petition is filed and adjudicated.

Entire Agreement. This Petition, including any attachments and declarations, constitutes the entire statement of facts and relief requested by Petitioner with respect to the matters herein and supersedes any prior statements or requests made to the court or agency regarding the same subject matter.

Severability. If any provision of this Petition is held invalid or unenforceable, the remaining provisions shall remain in full force and effect to the maximum extent permitted by law.

Amendments and Waiver. This Petition may be amended by Petitioner upon leave of the court; no waiver of any provision shall be effective unless in writing signed by the party waiving it and approved by the court where required.

Counterparts. This Petition may be executed in counterparts, each of which shall be deemed an original and all of which together shall constitute one instrument.

12. DECLARATION AND CERTIFICATION

I, the undersigned Petitioner, declare under penalty of perjury under the laws of the applicable jurisdiction that the foregoing statements are true and correct to the best of my knowledge and belief, and that I submit this Petition in good faith to secure such orders as are necessary to protect Respondent and others.

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