EXHIBIT F. PETITION FOR COURT-ORDERED TREATMENT

Gravely Disabled Person

IN THE SUPERIOR COURT OF THE STATE OF ARIZONA IN AND FOR THE COUNTY OF                                                          

In the Matter of                                               )

)       MH

)

)       PETITION FOR COURT-

)       ORDERED TREATMENT

)       (Pursuant to A.R.S. § 36-533)

re: Mental Health Services                               )       Danger to Self/Others or

)       Persistently or Acutely Disabled or

____________________________________)Gravely     Disabled

STATE OF ARIZONA                                       )

) ss COUNTY OF________________________ )

________________________________)

Petitioner ___________________________________________________, being first duly sworn/affirmed, alleges that: (Medical Director)

1. __________________________________________________________is, as a result of a mental disorder: danger to self                   danger to others

persistently or acutely disabled

gravely disabled

and in need of treatment.

2.        The court-ordered treatment alternatives that are appropriate and available are: outpatient treatment [A.R.S. § 36-540(A)(1)].

combined inpatient and outpatient treatment [A.R.S. § 36-540(A)(2)]. inpatient treatment [A.R.S. § 36-540(A)(3)] at.

3.        The person is unwilling or is unable to accept treatment voluntarily.

4.        A summary of the facts supporting the above allegations is in the attached reports of examining physicians.

5.       The person is residing or present in this county, or is admitted to an institution pursuant to an order of a court of competent jurisdiction sitting in this county, or who was committed by an Arizona tribal court, which order of commitment was duly domesticated pursuant to A.R.S. § 12-1702 et seq.

6.        The person is entitled to notice of hearing of the petition and may be found at___________________________________

(location)

_________________________________________________________________________________________________

7.        Petitioner believes the person requires a:

__________Title 14 guardian; __________ Conservator; __________Title 36 guardian

and requests the Court to order an investigation and report to be made to the Court regarding this need. Said need exists because:        __________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

8.       Petitioner believes the proposed person needs the immediate services of a temporary ______ guardian ______ conservator and requests that the Court appoint the same because: ______________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

9.     Petitioner believes that _____________________________________ address: ____________________________________, is the person’s guardian/conservator, who should receive notice of any hearing.

10.   A copy of this Petition has been mailed to the Public Fiduciary of ____________________________________________ County and (other guardian, if any)_________________________________________________________________________________

PETITIONER requests that the Court:

1.      Set a date for a hearing; and

2.      After notice and hearing find that the person is suffering from a mental disorder the result of which renders him/her dangerous to self or others, persistently or acutely disabled, or gravely disabled and order a period of treatment, all as set forth in paragraphs (1) and (2) above.

3.      Check if applicable;

Order an independent investigation and report to the Court regarding the need for a Title 14 guardian or conservator or Title 36 guardian.

Appoint the following-named person as temporary guardian and/or conservator of the person, who Petitioner believes to be a fit and proper person to serve in that capacity:

_______________________________________________                  ___________________________________________ (Proposed Temporary Guardian/Conservator)                                                      (Relation to Patient)

___________________________________________________________________________________________________ (Address of Proposed Temporary Guardian/Conservator)

Impose the duties of a Title 36 guardian upon the person’s A.R.S. Title 14 guardian who is __________________________

___________________________________________________________________________________________________

____________________________________                          __________________________________________________ DATE                                                                                         Signature of Petitioner

Medical Director

SUBSCRIBED AND SWORN to before me this __________ day of ____________________, 19______.

My Commission Expires:

__________________________________________________________________ NORTARY PUBLIC OR DEPUTY CLERK OF THE SUPERIOR COURT

_______________________________________

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 F repealed, new Exhibit F 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 R9-21-505 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).