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Petition Regarding Capacity To Consent To Or Refuse Anitipsychotic Medication RI-PR051 - California

Petition Regarding Capacity To Consent To Or Refuse Anitipsychotic Medication Form. This is a California form and can be used in Probate Riverside Local County .
 Fillable pdf Last Modified 3/4/2014
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SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE INDIO 46-200 Oasis St., Indio, CA 92201 RIVERSIDE 4050 Main St., Riverside, CA 92501 TEMECULA 41002 County Center Dr., # 100, Temecula, CA 92591 RI-PR051 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): IN THE MATTER OF: CASE NUMBER: PATIENT AT: PETITION REGARDING CAPACITY TO CONSENT TO OR REFUSE ANTIPSYCHOTIC MEDICATION (WELFARE AND INSTITUTIONS CODE §5332) I, 1. 2. 3. 4. 5. declare: , a physician licensed to practice medicine in the State of California, I am the treating physician for the referenced patient. The patient is currently being held at the above facility under Welfare and Institutions Code § 5000 et seq. The patient is presently showing symptoms of a mental disorder. In my professional opinion, the patient would benefit from the administration of the antipsychotic medications. I have discussed or attempted to discuss the proposed treatment with the patient. I have explained or attempted to explain to the patient the risks, benefits, possible side effects, and alternatives to treatment, and to obtain the patient's consent to receive medication. The patient has refused administration of antipsychotic medications. I have considered and determined that treatment alternatives to involuntary medication are unlikely to meet the needs of the patient. It is my opinion that the patient lacks capacity to give or withhold informed consent for treatment by antipsychotic medications. Pursuant to Welfare and Institutions Code § 5332, I request that a capacity hearing be held for a legal determination as to whether the patient has the capacity to give or withhold informed consent for treatment by antipsychotic medications. 6. 7. 8. 9. I declare under penalty of perjury under the laws of the State of California that the above is true and correct. Date: (SIGNATURE OF TREATING PHYSICIAN) Page 1 of 1 Approved for Optional Use Riverside Superior Court RI-PR051 [Rev. 2/13/14] PETITION REGARDING CAPACITY TO CONSENT TO OR REFUSE ANTIPSYCHOTIC MEDICATION (WELFARE AND INSTITUTIONS CODE § 5332) WIC § 5332 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com
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