Fill and Sign the Mc 120 Petition for 180 Day Commitment 12 87 Fill in Mental Commitment Forms

AS 47.30.770 Page 1 of 2 MC-120 (12/87)(cs) PETITION FOR 180-DAY COMMITMENT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) ________________________ ______, ) Case No. Respondent. ) ) PETITION FOR 180-DAY COM MITM ENT As a mental health professional who ha s examined the respondent, the petitioner alleges that: 1. The respondent is mentally ill and as a result is likely to cause harm to himself/herself or others. gravely disabled as previously alleged in the Petition for 90-Day Commitment. 2. The respondent: continues to be gravely disabled and there is reason to believe that the respondent's mental condition could be improved by a continued course of treatment. has attempted to inflict or has inflicted serious bodily harm upon himself/herself or another since hi s/her acceptance for evaluation. was committed initially as a result of conduct in which he/she attempted or inflicted serious bodily harm upon himself/herself or another. demonstrates a current intent to carry out plans of serious harm to himself/herself or another. 3. The evaluation staff has considered, but has not found, any less restrictive alternatives available that would a dequately protect the respondent or others. 4. is an appropriate treatment facility for the respondent's condition and has agreed to accept the respondent. 5. The respondent has received appropr iate and adequate care and treatment during his/her _______ day commitment. 6. The respondent has been advised of the need for, but has not accepted, voluntary treatment. The petitioner respectfully requests the court to commit the respondent to the above- named treatment facility for not more than 180 days. AS 47.30.770 Page 2 of 2 MC-120 (12/87)(cs) PETITION FOR 180-DAY COMMITMENT Case No. The facts and specific behavior of the res pondent supporting the above allegations are: The following persons are prospective witnesse s, some or all of whom will be asked to testify in favor of the commitment of the respondent at the hearing: Date Signature of Professional Person In Charge or that Person's Professional Designee Print Name and Title Verification Petitioner says on oath or affirms that petiti oner has read this petition and believes all statements made in the petition are true. Subscribed and sworn to or affirmed before me at , Alaska on (date) Clerk of Court, Notary Public or other person (SEAL) authorized to administer oaths. My commission expires: