IVC Affidavit Form

IVC Affidavit Form

This Affidavit is submitted by Affiant Name: of Affiant Address: and is provided to Requesting Party Name: for the purpose of establishing facts relevant to an involuntary commitment proceeding (IVC).

RECITALS

WHEREAS, Affiant possesses direct, personal knowledge of the facts set forth herein and makes this affidavit under penalty of perjury; and

WHEREAS, the subject of this affidavit is Subject Name: , Date of Birth: , presently located at Subject Address: , and these facts are submitted to establish risk of harm and need for involuntary commitment.

WHEREAS, the affiant seeks that the facts set forth be considered by the appropriate authority in connection with any petition, order, or proceeding that may be instituted or maintained for the protection of the subject or others.

NOW, THEREFORE

Affiant hereby declares and states under oath as follows:

1. AFFIANT IDENTIFICATION

2. STATEMENT OF FACTS

On Date of Observation: at approximate time: , I observed the following conduct by the subject which forms the basis for this affidavit:

The statements above are based on my own observations and, where noted, on information received directly from witnesses identified below.

3. MEDICAL, TREATMENT, AND HISTORY

Has the subject been previously hospitalized for psychiatric reasons? Yes No

4. DANGEROUSNESS AND RISK ASSESSMENT

Describe specific acts, threats, or behaviors that demonstrate risk of harm to self or others, including dates, locations, and any weapons or means involved:

Has law enforcement been contacted in relation to the subject's conduct? Yes No If yes, provide incident number or agency and summary:

5. REQUEST FOR RELIEF

Based upon the foregoing facts and assessments, Affiant requests that the appropriate authority consider the issuance of an involuntary commitment order or other protective measures as authorized by law, including evaluation, treatment, and detention for the subject to prevent imminent harm.

6. OATH, CERTIFICATION AND AUTHORIZATION

I, Affiant Name: , declare under penalty of perjury under the laws of the governing jurisdiction that the statements contained in this affidavit are true and correct to the best of my knowledge, information, and belief. I authorize the release of relevant information to persons or agencies responsible for conducting the IVC evaluation and necessary treatment.

Affiant contact telephone: | Affiant email:

7. NOTICES

All notices, requests, or other communications required or permitted under this affidavit shall be in writing and shall be delivered to the contact information provided above or to such other address as a party may designate in writing.

8. AMENDMENTS; WAIVER; COUNTERPARTS

This affidavit may be amended or supplemented in writing and signed by the affiant. No waiver of any provision shall be effective unless in writing and signed by the waiving party. This affidavit may be executed in counterparts, each of which shall be deemed an original.

9. GOVERNING LAW; ENTIRE AGREEMENT; SEVERABILITY

This affidavit shall be governed by and construed in accordance with the laws of the jurisdiction in which the relevant proceeding is filed. This affidavit contains the entire statement of facts and requests by the affiant for the purposes stated herein. If any provision of this affidavit is held invalid or unenforceable, the remaining provisions shall remain in full force and effect.

10. AFFIRMATION

I affirm under penalty of perjury that the foregoing representations are true and correct and that I am competent to make this affidavit.

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