Fill and Sign the Notice of Need for Transportation Order and Order Form

Physician Physician's Designee Representative Of Center (Title) AOC-SP-220, New 7/04 2004 Administrative Office of the Courts ORDER The Respondent has failed to comply, but does not clearly refuse to co mply, with all or part of the prescribed treatment after reasonable efforts to solicit compliance, in that (Summarize facts showing failure to comply and reasonable efforts to solicit compliance): STATE OF NORTH CAROLINA An Outpatient Commitment Order was entered in this proceeding on the date shown above and the Respondent was ordered to comply with prescribed treatment. The period of outpatient commitment has not expired. 1. 2. (OUTPATIENT FAILS BUT DOES NOT CLEARLY REFUSE TO COMPLY WITH TREATMENT) File No. In The General Court Of Justice District Court Division County REQUEST FOR TRANSPORTATION ORDER AND ORDER G.S. 122C-273(a)(2) Transport To (Name And Address Of Physician Or Center) REQUEST The outpatient physician, physician's designee or outpatient treatment center named below requests that the Clerk of Superior Court enter an order pursuant to G.S. 122C-273(a)(2) to take the Respon dent named above into custody and to take the Respondent immediately to the outpatient treatment physician or center specified ab ove for examination. In support of this request the undersigned states: Signature Of Physician, Physician's Designee Or Representative Of Center Name Of Physician Or Center (Type Or Print) TO ANY LAW ENFORCEMENT OFFICER: You are ORDERED to take the Respondent into custody, take the Resp ondent immediately to the specified outpatient treatment physician or center and turn the Respondent over to the custody of that physician or center. Signature Date Clerk Of Superior Court Assistant Clerk Of Superior Court Date NOTE: Use this form only when (1) an Outpatient Commitment Order has been entered after a hearing in district court; (2) the respondent has failed, but has not clearly refused, to comply with all or part of the prescribed treatment, and (3) the respondent is to be taken to a physician or outpatient treatment center for examinatio n. DO NOT use this form when the respondent has clearly refused to comply; instead use "Request For Supplemental Hearing (Outpatient Fails O r Clearly Refuses To Comply With Treatment)," AOC-SP-221. Other transportation orders are: "Notice Of Need For Transpo rtation Order (From One 24-Hour Facility To Another)," AOC-SP-222; "Request For Transportation Order And Order (Committed Subst ance Abuser Fails To Comply Or Is Discharged From 24-Hour Facility)," AOC-SP-223; Request For Transportation Order And Order (Out patient Fails To Appear For Prehearing Examination), AOC-SP-224. Date Of Outpatient Commitment Order Date Period Of Commitment Expires IN THE MATTER OF: Name And Current Address Of Respondent NOTE: See Side Two for Officer's Return. Name Of Person Signing Request (Type Or Print) PM OFFICER'S RETURN AOC-SP-220, Side Two, New 7/04 2004 Administrative Office of the Courts On the date and time shown above, I took the Respondent into custody. I took the Respondent immediately to the specified outpatient treatment physician or center and turned the Responden t over to the custody of that physician or center. Time Time PM AM AM DateRespondent Turned Over To Physician Or Center I DID NOT take the Respondent named above into custody because: DateRespondent Taken Into Custody Name Of Deputy Sheriff Or Law Enforcement Officer Making Return (Type Or Print) County Of Sheriff Or City Of Law Enforcement Officer Signature Of Deputy Sheriff Or Law Enforcement Officer Making Return Date Of Return