INFORMATION FOR FILING MENTAL HEALTH BOARD PETITION: The patient must be dangerous as well as mentally ill. There must be an overt act of dangerousness to the patient or to someone else occurring within the last three months. There must be information establishing mental illness. Subject must be found in Douglas County at time Petition is filed. The Petition will be presented to the Deputy County Attorney to determine if there is sufficient evidence of dangerous acts and mental illness for approval of the filing of the Petition. Petitioner and other witnesses must appear at the commitment hearing to give sworn testimony to the evidence of dangerousness to self or others as well as mental illness. The subject and his/her attorney will be present. Failure to appear might result in the dismissal of the Petition. A Public Defender will be appointed to represent the subject if he/she is indigent. The only testimony permitted to be introduced at the hearing is first-hand information. No hearsay evidence can be introduced. The commitment hearing will be held within 7 days after patient is admitted to hospital. Commitment by the Board of Mental Health is for persons who refuse voluntary treatment. The Board of Mental Health does not commit persons who are mentally retarded only. The Board of Mental Health does not pay for the care of patients or pay for the Physician while subject is in the hospital. A Petition has to be signed by a Notary if it is faxed or mailed to the Board of Mental Health. After 4:30 p.m. and weekend: Call 911 for emergency assistance. Board of Mental Health, 801 Civic Center 1819 Farnam Street Omaha, Ne. 68183 PHONE Number: 402-444-7191 FAX Number: 402-444-6455 Deputy County Attorney 909 Civic Center 1819 Farnam Street Omaha, Ne. 68183 PHONE Number: 444-7542 ---------------------------------------------------------------------------------------------------------------Nebraska Revised Statute 71-962 - VIOLATIONS; PENALTY. Any person who willfully (1) files, or causes to be filed, a certificate of petition under this act, knowing any of the allegations thereof to be false, (2) deprives a subject of any of the rights granted the subject by this act or section 71-956 or (3) breaches the confidentiality of records required by section 71-961 shall be guilty of a Class II Misdemeanor in addition to any civil liability which he may incur for such acts. -------------------------------------------------------------------------------------------------------------------------------------------------------- American LegalNet, Inc. www.FormsWorkFlow.com IN THE DISTRICT COURT, DOUGLAS COUNTY, NEBRASKA BEFORE THE MENTAL HEALTH BOARD OF THE FOURTH JUDICIAL DISTRICT OF THE STATE OF NEBRASKA, COUNTY OF DOUGLAS IN THE INTEREST OF CASE Number__________________ PETITION ALLEGED TO BE A MENTALLY ILL DANGEROUS PERSON } } } } } COMES NOW _______________________________________________, Petitioner, and alleges: That the above-named subject is now found at________________________________________________ Omaha, Nebraska, and that said ____________________________________________________is within Section 71-908 of the Rev. Stats. of Nebraska (2006) in that the subject is believed to be a mentally ill and dangerous person by reason of the behavior described in the attachments, contents of which are incorporated herein by reference: THAT neither voluntary hospitalization nor other treatment alternative less restrictive of the subject\ 's liberty than a mental health board ordered treatment disposition are available or would suffice to prevent the harm described in Section 71-908 of the Rev. Stats. of Nebraska (2006). THAT the immediate custody of the above named subject is/is not required to prevent the occurrence of such harm before a summons could be served and that a warrant/ summons issue. The hearing requested by the Petitioner may include a request for the Board to enter an Order authorizing the administration of psychotropic medication against the above-named subject's will. WHEREFORE, the petitioner prays for a hearing to determine whether the subject is a mentally ill dangerous person and what treatment alternative would suffice to prevent the above described harm. _________________________________________________ Petitioner STATE OF NEBRASKA § COUNTY OF DOUGLAS § _____________________________________________________being first duly sworn on oath, deposes and states that he/she is the person named in the above and foregoing petition, and that the facts contained therein are true and he/ she verily believes. _________________________________________________ Petitioner Subscribed and sworn to before me this ___________day of _____________________, 20____ ________________________________________________ Notary Public American LegalNet, Inc. www.FormsWorkFlow.com MENTAL HEALTH BOARD INTAKE INFORMATION DATE___________________ REPORTING PARTY: NAME ___________________________________________ RELATIONSHIP TO SUBJECT _______________________ ADDRESS____________________________________________________________________________________________ PHONE Number: HOME_________________ WORK ________________ CELL _________________ SUBJECT AND RISK DATA: NAME ____________________________________________ SOCIAL SECURITY NUMBER ________________________ IMMEDIATE LOCATION OF SUBJECT____________________________________________________________________ ______________________________________________________________________________________________________ **IF IN HOSPITAL, LIST ROOM, BED NUMBER, AND CONTACT PERSON: ______________________________________________________________________________________________________ CURRENT ADDRESS: _____________________________________ CITY / STATE / ZIP _______________________________________ PHONE Number: HOME_________________ WORK ________________ CELL _________________ DATE OF BIRTH ________________ AGE _________ COUNTY _________________ SEX: Male ______ or Female________ RACE __________________________ HEIGHT_______________ WEIGHT ____________________ HAIR COLOR ___________________ HAIR LENGTH _________ EYE COLOR ________________ WEARS GLASSES: Yes ____ No_______ FACIAL HAIR: Beard_______ Mustache ___________ TATTOOS (DESCRIPTION & LOCATION): ________________________________________________________________ ______________________________________________________________________________________________________ SCARS (LOCATION):_________________________________________________