Fill and Sign the Outpatient Fails to Appear for Prehearing Form

AOC-SP-224, New 7/04 Physician Representative Of Center (Title) Time Of Missed Appointment STATE OF NORTH CAROLINA File No. (OUTPATIENT FAILS TO APPEAR FOR PREHEARING EXAMINATION)In The General Court Of Justice District Court Division County IN THE MATTER OF: REQUEST FOR TRANSPORTATION ORDER AND ORDER G.S. 122C-265(a); 122C-263(f) Name And Current Address Of Respondent 2004 Administrative Office of the Courts Date Of Missed Appointment Date Of First Examination Name Of Examining Physician Or Eligible Psychologist Name And Address Of Proposed Outpatient Treatment Physician Or Center REQUEST NOTE: Use this form only when (1) a physician or eligible psychologist has conducted a first examination at the initiation of an involuntary commitment proceeding and has recommended outpatient treatment, (2) no hearing has yet been held in district court, (3) the physician or eligible psychologist has scheduled an appointment for t he Respondent with a proposed outpatient treatment physician or center and has provided the Respondent with written notice of the appointment, and (4) the Respondent has failed to keep the appointment. Other transportation orders are: Request For Tran sportation Order And Order (Outpatient Fails But Does Not Clearly Refuse To Comply With Treatment)," AOC-SP-220; "Notice Of Need For Transporta tion Order And Order (Outpatient Fails To Appear For Prehearing Examination)," AOC-SP-221; "Request For Transportation Order And Order (Committed Substance Abuser Fails To Comply With Treatment Or Is Discharged From 24-Hour Facility)," AOC-SP-223. The proposed outpatient treatment physician or center na med below requests that the Clerk of Superior Court enter an order, pursuant to G.S. 122C-265(a), to take the Respo ndent named above into custody and to take the Respondent to the outpatient treatment physician or center specified ab ove for examination. In support of this request, the undersigned notifies the Clerk that: 1. 2. The physician or eligible psychologist named above has conduct ed the first examination provided for in G.S. 122C-263 and has recommended outpatient treatmen t; no hearing has yet been held in district court. The physician or eligible psychologist scheduled an appointm ent for the Respondent with the proposed outpatient treatment physician or center named above for the date a nd time shown above, and provided the Respondent with written notice of the appointment and of the na me, address and phone number of that physician or center. 3. 4.The examining physician or eligible psychologist is differe nt from the proposed outpatient treatment physician or center. The Respondent failed to appear for examination at t he scheduled date and time. Signature Of Proposed Outpatient Treatment Physician Or Representative Of Center Date Name Of Proposed Outpatient Treatment Physician Or Center (Type Or Print) You are ORDERED to take the Respondent named above int o custody, take the Respondent immediately to the proposed outpatient treatment physician or center specifie d above and turn the Respondent over to the custody of th at physician or center. TO ANY LAW ENFORCEMENT OFFICER: ORDER Signature Clerk Of Superior Court Assistant Clerk Of Superior Court Date NOTE: See Side Two for Officer's Return. PM AM PM OFFICER'S RETURN 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 AOC-SP-224, Side Two, New 7/04 2004 Administrative Office of the Courts 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