Kentucky > Statewide > Involuntary Hospitalization
Verified Petition For Involuntary Treatment (Alcohol And Drug Abuse) AOC-700A - Kentucky
| Verified Petition For Involuntary Treatment (Alcohol And Drug Abuse) Form. This is a Kentucky form and can be used in Involuntary Hospitalization Statewide . |
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AOC-700A Doc. Code: PIHAD Rev. 10-06 Page 1 of 3 Commonwealth of Kentucky Court of Justice www.courts.ky.gov Case No. Court Verified Petition for 60/360 day inVoluntary treatment (alcohol/drug abuse) County _____________________ District ________________________ _______________________ KRS 222 IN THE INTEREST OF: RESPONDENT ___________________________________________________________________________________ RESPONDENT'S RESIDENCE ADDRESS ____________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ _________________________________________________________________________________________________ Current Location (if different) 1. PETITIONER, ________________________________________________________________________________ (Petitioner's Name-Please print) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ states that he/she is: [ 2. ] Spouse; [ ] Relative; (Petitioner's Address-Please print) [ ] Friend; or [ ] Guardian, of the above-named Respondent. PETITIONER further states that the name, address, and residence of persons related to the Respondent are: (if unknown, so state) Parents or guardian:_________________________________________________________________________________ Spouse:___________________________________________________________________________________________ Person having custody of Respondent:________________________________________________________________ Near relative:_______________________________________________________________________________________ Other:_____________________________________________________________________________________________ 3. PETITIONER believes that the Respondent is a person suffering from alcohol and/or other drug abuse because: (state facts to support belief) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com AOC-700A Doc. Code: Rev. 10-06 Page 2 of 3 4. PIHAD PETITIONER also believes that the Respondent presents a danger or threat of danger to self, family or others because: (state facts to support belief) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. PETITIONER requests that the Respondent be detained for examination, evaluation and hospitalization/ admittance to a treatment facility if he/she meets the criteria for: [ [ ] ] involuntary treatment for not more than sixty (60) consecutive days; or involuntary treatment for not more than three hundred and sixty (360) consecutive days. ______________________________________ Date ____________________________________________ Signature of Petitioner ____________________________________________ Name of Petitioner (please print) SUBSCRIBED AND SWORN TO before me this _________ day of __________________________, 2 _______. _________________________________________ Name/Title _________________________________________ County, Kentucky The Petitioner or other authorized person (spouse, relative, friend, or guardian) must guarantee all cost for treatment. Page 3, "Guarantee of Payment," must be completed and notarized. American LegalNet, Inc. www.FormsWorkFlow.com AOC-700A Doc. Code: Rev. 10-06 Page 3 of 3 PIHAD GUARANTEE OF PAYMENT Pursuant to KRS 222.432(4)(f), either the Petitioner or other authorized person (spouse, relative, friend, or guardian) shall guarantee any and all costs for treatment of the Respondent for alcohol and other drug abuse, as may be hereinafter ordered by the Court. The GUARANTEE below shall be completed by either the Petitioner or other authorized person. By my signature below, I do hereby assume responsibility for and GUARANTEE PAYMENT FOR ALL COSTS incurred on behalf of the respondent for all alcohol and other drug abuse treatment, including, but not limited to, initial examination and transportation costs, as hereinafter ordered by the Court. _______________________________________________ Date ________________________________________________ Relationship to Respondent (Petitioner, or Spouse, Relative, Friend, Guardian) ______________________________________ Name (please print) ______________________________________ Signature _________________________________________ _________________________________________ _________________________________________ SUBSCRIBED AND SWORN TO before me this _________ day of __________________________, 2 _______. Billing Address _________________________________________ Name/Title _________________________________________ County, Kentucky Attach copy of Verified Petition to each copy of Warrant, Summons, and Hearing, Examination and Appointment of Counsel Notice and Order. Distribution: Respondent; Petitioner; Respondent's Legal Guardian, Spouse, Parent(s), Near Relative or Friend (if applicable). American LegalNet, Inc. www.FormsWorkFlow.com
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