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Petition For Emergency Evaluation CC-DC 13 - Maryland
| Petition For Emergency Evaluation Form. This is a Maryland form and can be used in General Circuit-District Court Statewide . |
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CIRCUITCOURT DISTRICTCOURTOFMARYLANDFOR ............................................ City/County Locatedat....................................................................................CaseNo................................................ CourtAddress PETITIONFOR EMERGENCYEVALUATION (MarylandCode,Health-GeneralArticle 10-620et seq.) The Petitioner,...........................................................................................................,requests thatthisCourtorderanNameof Petitioneremergencyevaluationof..........................................................................................................................................andNameof persontobe evaluated(Evaluee)in supportof thisPetitionstatesas follows: 1. Petitioner:Address.................................................................................................................................................... CellPhone/Pager# .................................HomePhone....................................WorkPhone.................................... Relationshipto or interestin evaluee........................................................................................................................ 2. Evaluee:Address...........................................................................................................................DOB.................. Sex............Race.............Ht. ...............Wt. ...............Hair..................Eyes.................Complexion...................... DriversLicenseNo...........................................................................Other.............................................................. 3. If not Petitioner,nameof spouse,child,parent,or otherrelative,or otherindividualinterestedin the evaluee: Name....................................................................................Relationship................................................................ Address...................................................................................................................................................................... HomePhone........................................................................WorkPhone................................................................ 4. A petitionfor emergencyevaluationof the evalueewas filedpreviouslyon........................................................... Date(s) and was granted denied. 5. The evalueehasbeenhospitalizedin the past at the followingfacilities: ...................................................................................................................................................................................WhenWhereDiagnosis ................................................................................................................................................................................... 6. The evalueecurrentlyis receivingpsychiatrictreatmentfrom:WhenWhere Diagnosis ...................................................................................................................................................................................NameAddressPhone ................................................................................................................................................................................... Name Address Phone 7. The evalueehasbeenprescribedthe followingmedicationfor his/hermentaldisorder:......................................... ................................................................................................................................................................................... 8. The evaluee is is not takingthe medicationas prescribedOR I do notknow whetherthe evalueeis takingmedicationas prescribed. 9. The evalueeis demonstratingthe followingbehaviorthatleadsme to concludethathe/shecurrentlyhasa mentaldisorder:......................................................................................................................................................... ...................................................................................................................................................................................(Attachadditionalsheetif necessary)10. The evalueepresentsa dangerto the lifeor safetyof the evalueeor othersbecause:.............................................. ...................................................................................................................................................................................11. The evalueehasaccessto the followingfirearms/weapons:.....................................................................................(Attachadditionalsheetif necessary)I herebycertifyanddeclareunderthe penaltiesof perjurythatthe mattersand factsstatedin this Petitionaretrueto the best of my knowledge,information,andbelief. ...................................................................................... .................................................................................. Date Petitioner TO THE PETITIONER: You may be requiredto appearbeforethe Court.If an evaluationis ordered,it wouldbehelpfulif you couldaccompanythe evalueeto the emergencyfacilityandprovidefacilityauthoritieswithall informationthatis pertinentto thisPetition.A petitionerwho,in goodfaithand withreasonablegrounds,submitsorcompletesthe petitionfor emergencyevaluationis not civillyor criminallyliablefor submittingor completingthepetition. CC-DC13 (Rev.10/2004) (front) <<<<<<<<<********>>>>>>>>>>>>> 2 ENDORSEMENTAND ORDER In the matterof the emergencyevaluationof ...................................................................................................................(CaseNo.......................................................................),the Petitionerhavingpresentedto the Courtand thertCouhavingreviewedthe Petitionand consideredall pertinentdata presented,the Court: Findsprobablecausetobelievethatthenamedindividual(evaluee)hasshownthesymptomsofamental disorderand presentsa dangerto the lifeor safetyof the evalueeor othersand, therefore,ORDERSthatany peaceofficertakeinto custodyand transportthe evalueeto the nearestemergencyfacility,for examination by a physicianwithinsix hoursafterarrivalat the facilityand,if in the physiciansopinionnecessary,for emergencycareand treatment;providedthatthe facilitymay notkeepthe evalueefor morethan 30 hours underthis Orderb
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