STATE OF NORTH CAROLINA County IN THE MATTER OF: Name And Address Of Respondent File No. In The General Court Of Justice District Court Division Name And Address Of Attorney For Respondent APPOINTMENT OF COUNSEL AND NOTICE OF HEARING/REHEARING VOLUNTARY ADMISSION OF MINOR G.S. 122C-224.1 To The Attorney For Respondent Named Above: The respondent named above has been admitted to a 24-hour facility as a minor who is mentally ill or a substance abuser and is in need of treatment and is entitled to the appointment of counsel. You are appointed as the attorney to represent the respondent in this matter. A hearing will be held before a district court judge at the date, time and place indicated below. At that hearing it will be determined whether the Court concurs in the admission/readmission and whether the respondent's admission will be continued. Date Of Hearing Time AM PM Place Of Hearing I certify that I have mailed copies of this Notice by first class mail at least 72 hours before the hearing to the persons whose names and addresses are listed below: Name And Address Of Respondent's Legally Responsible Person Name And Address Of Responsible Professional At 24-hour Facility Date Signature Assistant CSC Clerk Of Superior Court RETURN OF SERVICE NOTE TO SHERIFF: This Notice must be served on the respondent's attorney at least 72 hours before the hearing. I certify this Notice was received and served on the respondent as follows: Date Served Name Of Respondent's Attorney By delivering to the respondent's attorney a copy of this Notice. By leaving a copy of this Notice at the dwelling house or usual place of abode of the respondent's attorney with a person of suitable age and discretion residing therein. Name And Address Of Person With Whom Copy Left Respondent's Attorney WAS NOT served for the following reason: Date Received Date Returned Name Of Deputy Sheriff Making Return (Type or Print) County Signature of Deputy Sheriff Making Return NOTE: "Upon the request of the legally responsible person or the minor admitted or committed, and after that minor has both been released and reached adulthood, the court records of that minor made in proceedings pursuant to Article 5 of [Chapter 122C] may be expunged from the files of the court." G.S. 122C-54(e) AOC-SP-912M, Rev. 7/11 © 2011 Administrative Office of the Courts