Fill and Sign the Supplemental Hearing Form

Date Of Request Signature Of Outpatient Treatment Physician, Physician's Designee Or Representative Of Center Name Of Outpatient Treatment Physician Or Center (Type Or Print) Name Of Person Signing Request (Type Or Print) REQUEST FOR SUPPLEMENTAL HEARING (OUTPATIENT CLEARLY REFUSES TO COMPLY WITH TREATMENT) STATE OF NORTH CAROLINA File No. In The General Court Of Justice District Court Division County G.S. 122C-273(a)(1) AOC-SP-221, New 7/04 2004 Administrative Office of the Courts NOTE: Use this form only when (1) an Outpatient Commitment Order has been entered after a hearing in district court; (2) the Respondent has clearly refused to comply with all or part of the prescribed treatment, and (3) a supplemental hearing is requested. DO NOT use this form when the Respondent has failed, but has not clearly refused to comply; instead use "Physician's Request For Transportation Order And Order (Outpatient Fails But Does Not Clearly Refuse To Comply With Treatment), AOC-SP-220. NO TRANSPORTATION ORDER SHOULD BE ISSUED ON THIS REQUEST. REQUEST The outpatient physician, physician's designee or outpatien t treatment center named below requests that the Clerk of Superior Court enter an order, pursuant to G.S. 122C -273(a)(1), for a supplemental hearing in this matter. In support of this request, the undersigned states: An Outpatient Commitment Order was entered in this pr oceeding on the date shown above, and the Respondent was ordered to comply with prescribed treatment. The per iod of commitment has not expired. 1. The Respondent clearly refuses to comply with all or part of the prescribed treatment after reasonable efforts to secure compliance, in that (Summarize facts showing clear re fusal to comply with treatment and reasonable efforts to solicit compliance.): 2. IN THE MATTER OF: Name And Current Address Of Respondent To order a supplemental hearing, the Clerk should use Order To Appear At Supplemental Hearing For Invol untary Commitment, AOC-SP-205, and check Finding #1 on that form. Physician Physician's Designee Representative Of Center (Title) NOTE: Date Of Outpatient Commitment Order Date Period Of Commitment Expires