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Arizona Administrative Code (Last Updated: November 17, 2016) |
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Title 9. HEALTH SERVICES |
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Chapter 21. DEPARTMENT OF HEALTH SERVICES |
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Article 5. COURT-ORDERED EVALUATION AND TREATMENT |
EXHIBIT B
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PETITION FOR COURT-ORDERED EVALUATION
IN THE SUPERIOR COURT OF THE STATE OF ARIZONA IN AND FOR THE COUNTY OF
In the Matter of )
) MH
)
) PETITION FOR COURT-
) (Pursuant to A.R.S. § 36-523)
)
re: Mental Health Services)
_______________________________ )
STATE OF ARIZONA )
)
COUNTY OF )
Petitioner, __________________________________________________________________________________________________ (Medical Director)
being first duly sworn/affirmed, alleges that:
1. There is now in this County a person whose name and address are as follows:
______________________________________________
________________________________________________________
(Name) (Address)
2. The person may presently be found at:________________________________________________________________________
______________________________________________________________________________________________________
3.
There is reasonable cause to believe that the person has a mental disorder and is as a result: A danger to self; A danger
to others;Gravely disabled; Persistently or acutely
disabled and is:4. The person is unwilling to undergo voluntary evaluation, as evidenced by the following facts:
___________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
5. The person is unable to undergo voluntary evaluation, as demonstrated by the following reasons: _________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
6. The person is believed to be in need of supervision, care, and treatment because of the following facts: ____________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
7. The conclusion that the person has a mental disorder is based on the following facts: ___________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
8. The conclusion that the person is dangerous or disabled is based on the following facts:_________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
9. The conclusion that all available alternatives have been investigated and deemed inappropriate is based on the following facts:
______________________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
10. Applicant information: ____________________________________________________________________________________ Name of Applicant:_______________________________________________________________________________________ Address of Applicant: _____________________________________________________________________________________ Relationship to or Interest in the Proposed Patient: ______________________________________________________________
______________________________________________________________________________________________________
11. In the opinion of the Petitioner, the person is _____ is not ____ in such a condition that, without immediate or continuing hospitalization, s/he is likely to suffer serious physical harm or inflict serious physical harm upon another person.
12. In the opinion of the Petitioner, evaluation should ____ should not ____ take place on an outpatient basis, based upon the following reasons:________________________________________________________________________________________
______________________________________________________________________________________________________
______________________________________________________________________________________________________
PETITIONER REQUESTS THAT THE COURT:
Issue an Order requiring the person to be given an ____ Inpatient ____ Outpatient evaluation.
___________________________________ __________________________________________________________________ DATE Signature Of Petitioner
___________________________________ __________________________________________________________________
Printed or Typed Name SUBSCRIBED AND SWORN to before me this _______ day of _________________________________, 19 _____.
__________________________________________________________
Notary Public
My Commission Expires:
___________________________________
Historical Note
Adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective October 7, 1992; received in the Office of the Secretary of State October 14, 1992 (Supp. 92-4). Exhibit B repealed, new Exhibit B adopted under an exemption from A.R.S. Title 41, Chapter 6 pursuant to Laws 1992, Ch. 301, § 61, effective September 30, 1993 (Supp. 93-3).
Renumbered from a position after R9-21-502 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).