Voluntary Treatment Agreement

VOLUNTARY TREATMENT AGREEMENT

IN THE CIRCUIT COURT OF COUNTY, WEST VIRGINIA

IN RE: Involuntary Hospitalization of

RESPONDENT Case No. - MH -

VOLUNTARY TREATMENT AGREEMENT

[W.Va. Code: §27-5-2(h)]

Now comes on this day of , , the Respondent, in person and by and through his or her counsel, and submits to the Court this VOLUNTARY TREATMENT AGREEMENT approved by both Respondent and Counsel for Respondent as reflected by the signature of each to this Agreement. Respondent requests the Court pursuant to West Virginia Code: § 27-5-2(h) to consider evidence on whether Respondent's circumstances make him or her amenable to outpatient treatment in a nonresidential or non-hospital setting, to consider whether appropriate outpatient treatment for Respondent is available in a nonresidential or non-hospital setting, to approve this Agreement, and to enter an Order finding amenability, available appropriate treatment, and releasing Respondent to outpatient treatment upon the terms and conditions of this Voluntary Treatment Agreement.

The terms and conditions of this Voluntary Treatment Agreement are as follows:

A. Respondent agrees to and will comply with all the terms and conditions set forth in this Voluntary Treatment Agreement as a condition of release. Respondent acknowledges that in the event he or she fails or refuses to comply with any of the terms and conditions of this Agreement, the court may order the Respondent taken into custody, brought for hearing before the Court, and involuntarily committed/hospitalized for examination and treatment pursuant to the provisions of West Virginia Code: § 27-5-3.

B. Respondent may request the court to modify or cancel this Agreement pursuant to the provisions of West Virginia Code § 27-5-2(h).

C. This Voluntary Treatment Agreement shall have an effective date of and shall remain in effect for which time period is:

Not more than six (6) months, inasmuch as the Respondent has not been involuntarily committed in the past two years.

Not more than two (2) years, since the Respondent has been involuntarily committed in the past two years, to-wit:

D. The following treatment provider(s) have been contacted by or on behalf of Respondent and have agreed to provide Respondent appropriate outpatient treatment or a combination of inpatient/outpatient treatment as more fully described hereinafter in the terms and conditions of treatment:

Treatment Provider / Location Address / Phone Number

E. As concerns the issue of availability of treatment, the following transportation arrangements have been made/are available, to make the proposed treatment accessible to Respondent:

F. As concerns the issue of availability of treatment, the following arrangements have been made/are available, for payment of the proposed treatment:

G. The specific TERMS AND CONDITIONS OF TREATMENT are as follows:

Treatment pursuant to this Agreement includes no days, or days of VOLUNTARY INPATIENT TREATMENT at the mental health/addiction treatment facility before or during outpatient treatment.

Respondent agrees to check him or herself in to said facility for treatment on the following date(s) or at any time the following described symptoms manifest during outpatient treatment:

Respondent agrees to not attempt to check him or herself out of VOLUNTARY INPATIENT TREATMENT during the time period(s) designated above for such inpatient treatment or for so long as the above-described symptoms remain manifest during the effective period of this Voluntary Treatment Agreement. Respondent accepts the voluntary inpatient treatment as a condition to the Court's finding of amenability to outpatient treatment and conditional release of Respondent to outpatient treatment.

Submitted, approved by, and given under our hands this day of , .