Arizona Administrative Code (Last Updated: November 17, 2016) |
Title 9. HEALTH SERVICES |
Chapter 21. DEPARTMENT OF HEALTH SERVICES |
Article 5. COURT-ORDERED EVALUATION AND TREATMENT |
EXHIBIT H PETITION FOR NOTICE
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IN THE SUPERIOR COURT OF THE STATE OF ARIZONA IN AND FOR THE COUNTY OF
In the matter of )
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_____________________________)
REGARDING:______________________________________________________________________________________________
Pursuant to A.R.S. § 36-541.01, with respect to the above-named patient, a person who was ordered to undergo treatment for a mental disorder as a danger to others pursuant to A.R.S. § 36-540 by a court order of the Superior Court of _______________________________ County, Case Number ___________________________________, the undersigned, a person other than a relative or victim of the person hereby asserting a legitimate reason for receiving such notice, does hereby petition the Court to require that the medical director of
_________________________________________________, the mental health treatment agency providing court-ordered treatment for said person, provide the undersigned with written notice of intention to release or discharge said person prior to the expiration of the period for treatment ordered by the Court, as provided for in A.R.S. § 36-541.01, and does hereby provide the following information required by A.R.S.
Legitimate reason for receiving notice: _______________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
The undersigned person demanding notice hereby agrees to advise the treatment agency in writing, by certified mail, return receipt requested, of any change in the address to which notice is to be mailed.
_______________________________________________________ Signature of Person Petitioning
_______________________________________________________ Printed or Typed Name of Petitioner
_______________________________________________________ Date
_______________________________________________________ Address to Send Notice
_______________________________________________________ Telephone Number of Applicant
IN THE SUPERIOR COURT OF THE STATE OF ARIZONA
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1. The Court having received a demand by __________________________________________________, a relative or victim of
__________________________________________________, a patient ordered by the Court to undergo treatment for a mental disorder as a danger to others, for written notice from the medical director of________________________________________, the mental health treatment agency providing court-ordered treatment for said patient, of intention to release or discharge said patient prior to the expiration of the period ordered by the Court, as provided for in A.R.S. § 36-541.01, which demand included all information required by A.R.S. § 36-541.01(D);
2. The Court having received a petition by __________________________________________________, a person other than a relative or victim of __________________________________________________, a patient ordered by this Court to undergo treatment for a mental disorder as a danger to others, asserting that the petitioner has a legitimate reason for receiving such notice and petitioning the Court to require that the medical director of _______________________________________________, the mental health treatment agency providing court-ordered treatment for said patient, provide the petitioner with written notice of intention to release or discharge said patient prior to the expiration of the period for treatment ordered by the Court, as provided for in A.R.S. § 36-541.01, which petition included all information required by A.R.S. § 36-541.01(D); and the Court, after considering said petition, having found that the petitioner has a legitimate reason for receiving prior notice.
THEREFORE IT IS ORDERED that the medical director of ________________________________________, a mental health treat- ment agency, shall not release or discharge the above-named patient from court-ordered inpatient treatment without first giving written notice of the intention to do so, in accordance with A.R.S. § 36-541.01(F), to:
____ The above-named relative of the patient
____ The above-named victim of the patient
____ The above-named petitioner found by the Court to have a legitimate reason for receiving prior notice.
IT IS FURTHER ORDERED that a copy of this Order for Notice shall be delivered to the above-named mental health treatment agency and shall be filed with the patient’s clinical record, and if the patient is transferred to another agency or institution, any orders for notice shall be transferred with the patient.
DATED this __________ day of _________________________, 19 _____
_______________________________________________________ SUPERIOR COURT JUDGE/COMMISSIONER
ADHS/BHS Form MH-128 (9/93)
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 H repealed, new Exhibit H 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 R9-21-509 by exempt rulemaking at 9 A.A.R. 3296, effective June 30, 2003 (Supp. 03-2).