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Mc 610 Notice of Right to Counsel 1 14 PDF Fill in Mental Commitment Forms 490102007

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IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Hospitalization o f: ) ) ) , ) Respondent. ) ) Case No. Date of Birth: ) ) NOTICE OF RIGHT TO COUNSEL RESPONDENT IS HEREBY NOTIFIED that the adm inistrator of a public treatment facility approved an Application for 48-Hour Emergency Commitment , and you will be held in custody for a period of 48 hours. During the 48 hours , the administrator may apply for, or already applied for, a court order to hold you in custody for five days. The Applicat ion for 48-Hour Emergency Commitment was submitted by and alleges that you are an intoxicat ed person who threatened, attempted to inflict, or inflicted physical harm on another, and that unless committed you are likely to inflict physical harm o n another; and/or is incapacitated by alcohol or drugs. Within five days a p etition may be filed, or has already been filed, seeking a 30-day commitment, in which case you will be given noti ce of the proceedings and an attorney will be appointed for you. You may contact an attorney of your choosing before then if you wish to contest your detention. If you cannot afford an attorney, an attorney will be appointed for you. I certify that on (date) at (time) , I gave a copy of this Notice, the Application for 48-Hour Emergency Commitment, and Certificate of Need to the respondent respondent’s guardian respondent’s attorney other (name) DateSignature Type or Print Name and Title

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Fill and Sign the Mc 610 Notice of Right to Counsel 1 14 PDF Fill in Mental Commitment Forms 490102007