Order Directing Emergency

ORDER DIRECTING EMERGENCY EVALUATION

At a term of the Family Court of the

State of New York, held in and for the

County of

at , New York,

on

PRESENT:

Hon.

Judge

A petition under Article of the Family Court Act, sworn to on , having

been filed in this court in the above-entitled proceeding alleging that

And the matter having duly come on to be heard before this Court; and

I. Required Determinations for Inpatient Examination [check applicable box(es)]:

A. This Court has jurisdiction over the petition and [specify person to be examined]:

[Check applicable box]:

is a person within the jurisdiction of this Court;

is a parent or other person legally responsible for the care of a child who is within the jurisdiction

of this Court; and

B. [Specify person to be examined]: , a person before the

court, has or may have a mental illness which is likely to result in serious harm to himself or herself

or others based upon the following evidence presented [specify]:

II. Required “Best Interests” and “Reasonable Efforts” Findings [Required in all cases in which

the person to be remanded is a child who is the Respondent in a proceeding under Articles 3 or 7 of

the Family Court Act or who is the subject of a proceeding under Article 10 of the Family Court Act or

Social Services Law §§358-a, 384-b or 392; check applicable boxes and provide case-specific reasons

in both A and B, below. If findings were previously made, so specify]:

A. Continued placement in the Respondent's home [check applicable box]: would would not

be contrary to the Respondent's best interests, based upon the following facts and for the

following specific reasons [specify particular facts and reasons]:

Specific documents or evidence supporting this finding include the following:

Mental health evaluation, dated

Testimony of

Other

; AND

B. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the

Respondent from the home, and, if the Respondent was removed prior to the date of the

hearing, to return the Respondent safely to his or her home:

were made as follows [specify reasonable efforts]:

were not made but the lack of such efforts was appropriate based upon the following

facts and for the following reasons [specify particular facts and reasons]:

were not made.

Specific documents or evidence supporting the finding in B include the following:

Mental health evaluation, dated

Testimony of

Other

NOW, therefore, it is

ORDERED that [specify]:

is remanded to [check applicable box]:

The following hospital specified in section 9.39(a) of the Mental Hygiene Law

[specify]:

OR

The following comprehensive psychiatric emergency program described in section

9.40(a) of the Mental Hygiene Law [specify]:

for a determination by the director of such hospital or program whether such person should be retained

therein pursuant to such section; and it is further

ORDERED that the director of the hospital or program to which the remand is made shall, within

days after the completion of such examination, submit a report to this Court; and it is further

ORDERED that this proceeding is adjourned to [specify date]: (and it is further)

(ORDERED ).

PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS

ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT

IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY

THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY

FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST.

ENTER

Judge of the Family Court

Dated:

Check applicable box:

Order mailed on [specify date(s) and to whom mailed ]:

Order received in court on [specify date(s) and to whom given]: