SUPERIOR COURT OF CALIFORNIA, COUNTY OF RIVERSIDE RIVERSIDE 4050 Main St., Riverside, CA 92501 RI-PR064 ATTORNEY OR PARTY WITHOUT ATTORNEY (Name, State Bar Number and Address) FOR COURT USE ONLY TELEPHONE NO.: E-MAIL ADDRESS (Optional): ATTORNEY FOR (Name): FAX NO. (Optional): IN THE MATTER OF: CASE NUMBER: PETITION FOR EVALUATION Note to petitioner: You may not file this petition with the court. Only the Department of Mental Health may file this petition. Any individual who seeks a petition for court-ordered evaluation knowing that the person for whom the petition is sought is not, as a result of mental disorder, a danger to himself, or to others, or gravely disabled is guilty of a misdemeanor, and may be held liable in civil damages by the person against whom the petition was sought. 1. Person seeking evaluation (Petitioner): a. b. Your full name: Your address: City: Telephone: E-mail address: State: Fax: Zip: Age: 2. Person to be evaluated: a. b. e. Full name: Sex: Address: City: State: Zip: c. Marital status: d. Occupation: Age: 3. Person(s) responsible for the care,support, and maintenance of the person to be evaluated: a. b. Full name: Address: City: c. Relationship to person in (2): State: Zip: Age: Approved for Optional Use Riverside Superior Court RI-PR064 [Rev. 01/05/15] PETITION FOR EVALUATION Page 1 of 2 Welfare and Institutions Code § 5205 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com IN THE MATTER OF: CASE NUMBER: d. e. Full Name: Address: City: State: Age: Zip: f. 4. Relationship to person in (2): Relationship of parties: a. b. How do you know the person in (2)? (Explain below): How do you know the person(s) in (3)? (Explain below): 5. Reason for evaluation a. The person in (2) is, as a result of mental disorder (check all that apply): A danger to others. A danger to himself or herself. Unable to provide for his or her basic personal needs for food, clothing, or shelter due to reasons other than intellectual disabilities. b. State the facts that show that this petition should be granted: (1) (2) When did it happen? (Provide date or estimated date): Who else was there? (3) What did the person in (2) do? (Explain below): c. Are there other incidents where the person in (2) demonstrated that he or she needs evaluation? Yes No (If yes, describe prior incidents and provide dates below. If there is not enough space for your answer put your complete answer on the Form MC-025 and write "Attachment 5c-Previous Incidents" for a title): I ask the court to find that there is probable cause that the person in (2) is, as a result of mental disorder, a danger to others, or to him or herself, or gravely disabled and to order the person to submit to an evaluation of his or her condition at a time and place designated by the judge. Date: (ATTORNEY'S NAME (IF ANY)) (SIGNATURE) I declare under penalty of perjury under the laws of the State of California that the information above and on all attachments is true and correct. Date: (TYPE OR PRINT YOUR NAME) (SIGNATURE) Approved for Optional Use Riverside Superior Court RI-PR064 [Rev. 01/05/15] PETITION FOR EVALUATION Page 2 of 2 Welfare and Institutions Code § 5205 riverside.courts.ca.gov/localfrms/localfrms.shtml American LegalNet, Inc. www.FormsWorkFlow.com