Fill and Sign the Voluntary Treatment Agreement Inv 14pdf Fpdf DOC DOCX Form

IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §27-5-2(h)] Now comes on this ______ day of _______________, 2___, 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 reflect ed 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 ap propriate treatment, and releasing Re spondent to outpatient treatment upon the terms and conditions of this Voluntary Treatment Agreement. The terms and conditions of this Volunt ary 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 th e Respondent taken into custody, brought for hearing before the C ourt, and involuntarily committed/hospitali zed 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 CL MH07 INV 14 C. This Voluntary Treatment Agreement shall have an effective date of _________________________, 2_____, and shall remain in effect for [insert applicable time period] _____________________________________________, __________________________________which time period is: [initial appropriate maximum time period] _____ Not more than six (6) months, inasmuch as the Res pondent 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: [ insert date and place of last involuntary commitment ] ______________________________________________ ______________________________________________________________________\ _______________. 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 tr eatment 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: _______________________________________________________________________\ _ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ __________________________________. C CL MH07 INV 14 G. The specific TERMS AND CONDITIONS OF TREATMENT are as follows: [Recite specific terms and conditions of the treatment to be o ffered by the treatment provider and accepted by the Respondent together with specific obligations of the Respondent in connection with that treatment. Attach additional pages as necessary.] Treatment pursuant to this Agreement includes [check appropriate box ] ” no days, or ” ________ days [insert number of days ] of VOLUNTARY INPATIENT TR EATMENT at the ____________________________________________ mental health/addiction treatment facility [check appropriate box] ” before or ” during outpatient treatment . Respondent agrees to check him or herself in to said facility for treatment on the following date(s) [insert date(s)] ______________________________________ or at any time the following described symptoms manifest during outpatient treatment: [describe symptoms ] ____________________ ________________________________________________________________________\ ___________________________________ ________________________________________________________________________\ ___________________________. 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 t he effective period of this Voluntary Treatme nt Agreement. Respondent accepts the volunt ary inpatient treatment as a condition to the Court's finding of amenability to outpatient treatment and conditional release of Respondent to outpatient treatment. ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ ________________________________________________________________________\ _____________________________ [ attach additional pages as necessary] Submitted, approved by, and given under our hands this ______ day of __________________, 2______. _____________________________________________________________ RESPONDENT ____________________________________________________________ COUNSEL FOR RESPONDENT C CL MH07 INV 14