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Petition To Set Hearing To Determine Involuntary Participation Of Treatment Of Hospitalized Person 735 - Kentucky
| Petition To Set Hearing To Determine Involuntary Participation Of Treatment Of Hospitalized Person Form. This is a Kentucky form and can be used in Hospitalization-Disability Statewide . |
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AOC-735 Doc. Code: PHDIT Case No. Rev. 7-02 Page 1 of 1 Court District Commonwealth of Kentucky PETITION TO SET HEARING TO Court of Justice www.kycourts.net DETERMINE INVOLUNTARY County PARTICIPATION OF TREATMENT OF KRS 202A.196; 202B HOSPITALIZED PERSON IN THE INTEREST OF: Name: Address: 1. COMES PETITIONER, (name) _________________________________________________________________, and states he/she is a: [ ] Qualified Mental Health Professional [ ] Qualified Mental Retardation Professional employed at __________________________________________________________________________________ located at _____________________________________________ , ________________________________________ Street City ___________________________________ , Kentucky. 2. PETITIONER states he/she believes Respondent, a current patient/resident at said Hospital/Facility, should be ordered to accept treatment as prescribed by his/her Treating Physician. 3. PETITIONER states Respondent has refused to accept or participate in a Treatment Program individualized for his/her needs. 4. PETITIONER states a Review Committee met with Respondent and his/her [ ] Counsel [ ] other Representative, (Name) ____________________________________________________________________________________, and concluded Respondents prescribed Treatment Plan was appropriate; necessary to protect himself/herself or others from harm; the proposed treatment is the least restrictive alternative mode of treatment presently available; and the treatment prescribed would reasonably benefit him/her. 5. PETITIONER further states Respondent has had the gains and risks of the proposed Treatment Plan explained to him/her, and his/her [ ] Counsel or [ ] other Representative. 6. THEREFORE, Petitioner prays a de novo Determination Hearing be set within seven (7) days to determine if Respondent should be ordered to participate in his/her prescribed Treatment Plan. Date: ___________________, 2_____. ____________________________________________ Signature of Petitioner Subscribed and sworn to before me this _______ day of _______________, 2_____. My Commission expires: _________________________, 2_____. _____________________________________________ Notary Public _____________________________________________ County, Kentucky
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