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IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NO. DEFENDANT JUDGMENT OF COMMITTAL OF A CHEMICALLY DEPENDENT PERSON FOR TREATMENT THIS CAUSE came on to be heard on the , day of , , and the Court after considering said Petition and after finding that it enjoys both subject matter and personal jurisdiction, does hereby find as follows, to-wit:1.Plaintiff, is an adult resident citizen of County, Mississippi, residing at '' and defendant is an adult resident citizen of County, Mississippi, presently residing with the Plaintiff at .2. Defendant is a chemically dependent person, i.e. he/she is powerless over controlled substances, alcohol, specifically , mood altering chemical, and his/her life has thereby become unmanageable. Defendant is dehydrated to the extent that he/she had to be committed to a hospital over the past week due to alcoholism. He/She is suffering from withdrawal, refuses to ingest any nourishment only alcohol, and is making serious dangerous threats to any person he/she comes in contact with. 3.The Defendant's mental and physical health, his/her continued family life and his/her position in the community are dependent on his/her treatment at a chemical dependency unit. 4.The Plaintiff has selected a particular treatment facility located in the State of Mississippi, which has been approved by the Department of Mental Health, division of alcohol and drug abuse. The Defendant is presently a voluntary resident at , , Mississippi, which is where Plaintiff desires for Defendant to remain. 5.The Defendant has health insurance and the Plaintiff is able to provide for the payment of any payments for the Defendant's treatment at said facility. 6. The Defendant has executed a Waiver and Joinder to waive the requirement of any further notice of summons upon his/her and is voluntarily committing himself/herself without contesting said committal, and waived the requirement of a hearing and physical examination by a physician. 7.The Plaintiff suggested that the Defendant be committed for a period of not more that ( ) months or until the institution determines that his/her treatment is complete, whichever is earlier. 8.Defendant is under the influence of alcohol, mood-altering chemicals, to the extent that if he/she is served with process he/she will, in all likelihood, flee the jurisdiction of the Court or physically harm himself/herself and others as he/she has threatened to do. IT IS THEREFORE ORDERED AND ADJUDGED that , shall be and is hereby committed to the , , MS in the Chemical Dependency Unit and shall remain there for a period of not less that ( ) months, until the institution determines that his/her treatment is complete, whichever is earlier. IT IS FURTHER ORDERED AND ADJUDGED that should the Defendant voluntarily remove himself/herself from said facility without the consent and approval by said institution, the Sheriffs of and County, Mississippi, or any other law officer shall immediately pick up said defendant and return him/her to the , , MS without further orders of this Court. SO ORDERED AND ADJUDGED this the day of . _________________________________________C H A N C E L L O R __________________________________ ATTORNEY FOR PLAINTIFF IN THE CHANCERY COURT OF COUNTY, MISSISSIPPI PLAINTIFF VS. CIVIL ACTION NO. DEFENDANT VOLUNTARY WAIVER, ENTRY OF APPEARANCE AND ADMISSION OF ALLEGATIONS I, , the undersigned Defendant in this action, do hereby waive service of any legal citation or other legal process pursuant to Rule 4 (c), Mississippi Rules of Civil Procedure and enter my appearance and herein in this matter. I am not mentally incompetent, an unmarried minor, a lunatic or a convict of a felony. I admit the truth and correctness of the allegations in the Petition filed on the day of , , at least one day ago. I freely and voluntarily waive all notice of any hearing, waive the holding of any hearing required by Section 41-31-5, Mississippi Code of 1972, and annotated as amended, and waive any examination of any physician. I freely volunteer to be committed as requested by the Plaintiff. THIS the day of . _________________________________________ , DEFENDANT STATE OF MISSISSIPPI COUNTY OF PERSONALLY appeared before me, the undersigned authority, in and for the county and state aforesaid, the within named, , who, being by me first sworn on her oath, states that the matters, facts, averments and things set forth, contained and alleged in the Waiver are true and correct as therein stated, and said Waiver and Joinder are executed by the Defendant herein by her own free and voluntary act and deed, on the date therein stated. __________________________________________ SWORN TO AND SUBSCRIBED before me, this the day of , . _________________________________________NOTARY PUBLIC My Commission Expires:________________________