Agreement For Judgment And For Payment Order {DC-SC-8}

IN THE CIRCUIT COURT OF _______________ COUNTY, WEST VIRGINIA For Clerk's Use Only IN RE: INVOLUNTARY HOSPITALIZATION OF ___________________________________, RESPONDENT DATE: ____________________________________________ CASE NUMBER ___________ - MH - __________ If this application is GRANTED, distribute copies of the application and Pickup/Custody Order (Form INV 4 / Form 903CCF or INV 5 / Form 903CCF24) to: Applicant, Respondent, Respondent's Attorney, Prosecuting Attorney and the Regional Mental Health Center. APPLICATION FOR INVOLUNTARY CUSTODY FOR MENTAL HEALTH EXAMINATION [West Virginia Code: § 27-5-2] DO NOT USE THIS FORM IF THE PERSON TO BE EXAMINED IS INCARCERATED IN A JAIL, PRISON, OR OTHER CORRECTIONAL FACILITY [USE FORM INV 2 / FORM 901C] INSTRUCTIONS TO APPLICANT: A. B C. D. E. READ THOROUGHLY the IMPORTANT INFORMATION TO APPLICANTS attached. All information must be printed or typed and be clearly readable. All information requested must be provided, if known. If unknown, you must state it is unknown. Any petition and application which does not provide the necessary information, or is unreadable, may be rejected or denied. Read and answer all questions carefully. In this document, the RESPONDENT is the person whose examination is requested. 1. FULL NAME OF PERSON TO BE EXAMINED [RESPONDENT]:_____________________________________________________ Identification Information of Respondent:: DATE OF BIRTH ____/_____/________; WEIGHT __________; HAIR COLOR ________________; HAIR LENGTH ___________; SEX ________; HEIGHT __________; EYE COLOR ______________; RACE ______________. 2. RESPONDENT'S LAST KNOWN ADDRESS: _______________________________________________________________________ ______________________________________________________________________________________________________________ RESPONDENT'S TELEPHONE NUMBER: ( ) _______________________________________ 3. 4. PLACE OF BIRTH [state or country]________________________________________________________________________________ WHERE IS RESPONDENT NOW? PROVIDE ADDRESS: ___________________________________________________________ ______________________________________________________________________________________________________________ PROVIDE DIRECTIONS IF KNOWN: _____________________________________________________________________________ ______________________________________________________________________________________________________________ 5. THE RESPONDENT IS: A. B. A RESIDENT OF ___________________________________ COUNTY, _____________________ STATE. CURRENTLY PRESENT IN ___________________________________ COUNTY, __________________ STATE. C CL MH08 INV 1; SCA-MH 901/ 11-23 Application & Instructions Page 1 of 8 American LegalNet, Inc. www.FormsWorkFlow.com 6. 7. APPLICANT'S [your] FULL NAME :______________________________________________________________________________ APPLICANT'S [your] MAILING ADDRESS: _______________________________________________________________________ ______________________________________________________________________________________________________________ APPLICANT'S TELEPHONE NUMBER: WORK: ( ) ____________________ HOME: ( ) ___________________ PLEASE PROVIDE A WAY TO CONTACT YOU PENDING THIS APPLICATION PROCESS (example: cell phone, pager number). THE COURT MUST BE ABLE TO REACH YOU AND NOTIFY YOU OF THE TIME AND PLACE OF ANY HEARING, WHICH WILL BE HELD IMMEDIATELY TO WITHIN 24 HOURS. YOUR FAILURE TO APPEAR AT THE HEARING MAY RESULT IN THE APPLICATION BEING DISMISSED AND THE RESPONDENT BEING RELEASED. If you do not want the Respondent to have this information, you may supply the information separately to the Court. PHONE, CELL, PAGER OR OTHER PHONE NUMBER TO REACH APPLICANT: _______________________________________________________ 8. 9. WHAT IS YOUR RELATIONSHIP TO THE RESPONDENT?___________________________________________________________ DO YOU BELIEVE THE RESPONDENT IS: A. B. ADDICTED TO DRUGS, ALCOHOL AND/OR OTHER SUBSTANCES? MENTALLY ILL? __________YES __________YES __________NO __________NO 10. 11. HOW LONG HAS THE RESPONDENT SHOWN SUCH BEHAVIOR? _________________________________________________ IN YOUR OWN WORDS, PROVIDE ANY INFORMATION WHICH SUPPORTS YOUR BELIEF THAT THE RESPONDENT IS ADDICTED AND/OR MENTALLY ILL: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ (Attach additional pages if necessary) 12. DO YOU BELIEVE THE RESPONDENT, BECAUSE OF MENTAL ILLNESS OR ADDICTION, IS LIKELY TO CAUSE SERIOUS HARM TO: A. B. HIM/HER SELF? OTHER PEOPLE? __________YES __________YES __________NO __________NO 13. LIST ANY AND ALL RECENT ACTS WHICH SUPPORT YOUR BELIEF THAT THE RESPONDENT IS LIKELY TO CAUSE SERIOUS HARM TO HIM/HER SELF AND/OR OTHERS. INCLUDE APPROXIMATE DATE(S) WHEN EACH ACT OCCURRED: ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ ______________________________________________________________________________________________________________ (Attach additional pages if necessary) C CL MH08 INV 1; SCA-MH 901/ 11-23 Application & Instructions Page 2 of 8 American LegalNet, Inc. www.FormsWorkFlow.com A. IS RESPONDENT A SUICIDE RISK? _______ YES _______ NO _______ UNKNOWN IF YES, EXPLAIN: _____________________________________________________________________________________ ______________________________________________________________________________________________________ B. IS RESPONDENT VIOLENT? _______ YES _______ NO _______ UNKNOWN IF YES, EXPLAIN: _______________________