Fill and Sign the Mc 625 Petition for 30 Day Involuntary Commitment 5 10 Mental Commitment Form

IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Hospitalization of: ) ) ) , ) Respondent. ) Case No. ) Date of Birth: ) PETITION FOR 30-DAY ) INVOLUNTARY COMMITMENT 1. I hereby petition the Court for a 30-day involuntary commitment of the respondent named above pursuant to AS 47.37.190. 2. I am the certifying physician, physician assistant, or advanced nurse practitioner respondent’s spouse respondent’s guardian respondent’s relative administrator in charge of an approved public treatment facility 3. I believe that the respondent is an alcoholic or drug abuser * who threatened, attempted to inflict, or inflicted physical harm on another, and that unless committed is likely to inflict physical harm on another. is incapacitated by alcohol or drugs. 4. The reasons for my belief as to the respondent’s condition are as follows: Page 1 of 2 AS 47.37.190 MC-625 (5/10)(cs) *AS 47.37.270(1) defines an alcohol or drug abuser as a person who demonstrates increased tolerance to alcohol or drugs, who suffers from withdrawal when alcohol or drug s are not available, whose habitual lack of self-control concerning the use of alcohol or drugs causes significant hazard to the person’s health, and who continues to use alcohol or drugs despite the adverse consequences. Page 2 of 2 AS 47.37.190 MC-625 (5/10)(cs) PETITION FOR 30-DAY INVOLUNTARY COMMITMENT 5. This application is accompanied by a Certificate of Need for Emergency/ Involuntary Commitment prepared by a physician, physician’s assistant, or advanced nurse practitioner, who examined the respondent within two days before submission of this petition. The respondent refused to undergo a medical examination. Date Petitioner Type or Print Name Mailing Address Phone and Fax Verification Petitioner says on oath or affirms that petitioner 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: I certify that on , a copy of this petition was sent to: Petitioner Respondent/Guardian Respondent’s Attorney Administrator Other