Fill and Sign the Mh 907 Form

IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT PROBABLE CAUSE ORDER: FOR RELEASE TO OUTPATIENT TREATMENT PURSUANT TO VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §§ 27-5-2(f) and 27-5-2(h)] This matter was heard on the __________ day of ___________________________, 20________. The Applicant in this cause, _______________________________________, a ppeared in person [check appropriate item ] ___pro se, or ___ was represented by_______________________________________, Assistant/Prosecuting Attorney of ______________________ County, West Virginia. The Respondent appeared in person and by appointed counsel, ___________________________________. Testimony was also presen ted by, ___________________________________________________________, the examining Physician/ Psychologist/Court approved Licensed Clinical Social Worker or Advanced Nurse Practitioner with Psychiatric Certification. Testimony was also heard from [list witnesses ]: __________________________________________________________________ ________________________________________________________________________\ ______________________________. After hearing the testimony of witnesses and receiving all relevant evidence, and upon examination of the written report and certification of the Examiner, and the arguments of counsel for the parties, the Court makes the following FINDINGS [initial appropriate items ]: The Respondent _________IS _________IS NOT a resident of ___________________________ County, West Virginia. The Respondent _________WAS _________WAS NOT found in ___________________________ County, West Virginia. The Court further FINDS that there is [initial appropriate items ]: __________ PROBABLE CAUSE __________ NO PROBABLE CAUSE to believe the Respondent is addicted. __________ PROBABLE CAUSE __________ NO PROBABLE CAUSE to believe the Respondent is mentally ill. SCA-MH 907-1 / 6-06 VOLUNTARY TREATMENT AGREEMENT ORDER Page 1 of 3 SCA-MH 907-1 / 6-06 VOLUNTARY TREATMENT AGREEMENT ORDER Page 2 of 3 The Court further FINDS probable cause to believe that the Respondent [ initial one] __________IS __________ IS NOT likely to cause serious harm to him/her self and/or others because of his or her mental illness or addiction if allowed to rema in at liberty. The specific facts upon which these findings of probable cause are based are as follows: ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ______________________________________________________________ Notwithstanding the foregoing, the undersigned further FINDS that the Respondent's circumstances make him/her amenable to outpatient treatment in a nonresidential or nonhospital setting pursuant to a Voluntary Treatment Agreement beginning on the ______ day of _______________, 20_______, based upon the following: [state the evidence presented, or other basis, in support of this finding ] ______________________________________________________________________\ _____________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ _____ The undersigned further FINDS that appropriate outpatient tr eatment is available, to-wit:_____________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ _____ SCA-MH 907-1 / 6-06 VOLUNTARY TREATMENT AGREEMENT ORDER Page 3 of 3 The undersigned has also reviewed the Voluntary Treatment Agreement submitted by Respondent, dated the __________day of _______________________, 20 ____, does hereby approve the same, a copy of which is attached hereto and made a part hereof, the contents of which are hereby incorporated herein by reference. Therefore, the undersigned hereby ORDERS that the Respondent shall be: [initial appropriate finding] ________ involuntarily committed to the custody of the Secr etary of the Department of Health and Human Resources for initial placement at ______________________________________ mental health facility until the effective date of the Voluntary Treatment Agreement; further examined and/or treated as required under the provisions of West Virginia Code § 27-5-3 until the effective date of the Voluntary Treatment Agreement; and upon the effective date of the Voluntary Treatment Agreement conditionally released to outpatient treatment upon the terms and conditions set fo rth in the Voluntary Treatment Agreement. Discharge or release of the Respondent pursuant to the provisions of West Virginia Code §§ 27-7-1, et. seq., and/or § 27-5-3, during the involunt ary inpatient commitment period set forth hereinabove and prior to conditional release upon the Voluntary Treatment Agreement shall supersede this provision for release upon the Voluntary Treatment Agreement. _________ conditionally rel eased to outpatient treatment upon the terms and conditions set forth in the Voluntary Treatment Agreement. This ORDER and the incorporated Voluntary Treatment Agreement shall remain in effect for [insert applicable time period ] ____________________________________________________________, which time period is [initial applicable time period ]: ___________ Not more than six (6) months, inasmuch as the court hereby finds that the Respondent has not been involuntarily committed in the past two years. ___________ Not more than two (2) years, since the court hereby finds that the Respondent has been involuntarily committed in the past two years, to-wit: [insert date and place of last involuntary commitment ] ________ ________________________________________________________________________\ __________ The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit attested copies thereof, together with the voluntary treatment agreement attached hereto , to the Applicant, the Respondent, to all counsel of record, the Secretary of the Department of Health and Human Resources and to ________________________________________________ Mental Health Center. ____________________________________________________________________\ __ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE / MAGISTRATE