West Virginia > Statewide > Circuit Court > Mental Hygiene
Voluntary Treatment Agreement SCA-MH-907B - West Virginia
| Voluntary Treatment Agreement Form. This is a West Virginia form and can be used in Mental Hygiene Circuit Court Statewide . |
|
||||||
 Get this form for FREE as a print-only pdf |
|||||||
|
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(b)(6)] THIS VOLUNTARY TREATMENT AGREEMENT made this ___________ day of _______________________,20_____, by and between ____________________________________, Respondent, ___________________________, counselfor the Respondent, ___________________________________________ mental health center/mental health treatment providerand ________________________________________, Magistrate/Mental Hygiene Commissioner/Circuit Judge, WITNESSETH , that in consideration of the agreement made as stated herein between the Respondent and his or hercounsel and the mental health center/treatment provider, and with the further agreement of the presiding magistrate/mental hygienecommissioner/circuit judge, as the same is reflected by the signature of each to this instrument, that appropriate outpatient treatmentof the Respondent in a nonresidential or nonhospital setting is both appropriate and available, the undersigned agree that theRespondent shall be released to outpatient treatment pursuant to this voluntary treatment agreement subject to the following termsand conditions: [Recite specific terms and conditions of the treatment to be offered to and accepted by the Respondent together withspecific obligations of the Respondent in connection with that treatment. Attach additional pages as necessary.]__________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ SCA-MH 907B-1 / 5-01 <<<<<<<<<********>>>>>>>>>>>>> 2 27-5-2 VOLUNTARY TREATMENT AGREEMENT - Page 2 of 2 [terms and conditions - continued] __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ [attach additional pages as necessary] The outpatient treatment pursuant to this Agreement shall be at the direction of the mental health center/mental health provider and shall remain in effect for: [ initial applicable time period] ___________ 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: [ insert date and place of last involuntary commitment ] _________________________________________________. Furthermore, Respondent acknowledges that in the event Respondent fails or refuses to comply with any of the terms and conditions of the treatment as set forth herein, the court may after the hearing order involuntary hospitalization for examination and treatment pursuant to the provisions of West Virginia Code: 27-5-3. The Respondent has a right to petition the court at any time to modify or cancel this agreement. Given under our hands as and for the day and date first abovementioned. _____________________________________________________________ RESPONDENT ____________________________________________________________ COUNSEL FOR RESPONDENT ___________________________________________________________ MENTAL HEALTH CENTER/MENTAL HEALTH PROVIDER ___________________________________________________________ MAGISTRATE / MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE SCA-MH 907B-2 / 5-01
|
|||||||
