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Petition For 180-Day Commitment Form. This is a Alaska form and can be use in Mental Commitment Statewide.
Tags: Petition For 180-Day Commitment, MC-120, Alaska Statewide, Mental Commitment
Page 1 of 2 AS 47.30.770 MC-120 (3/19)(cs) PETITION FOR 180-DAY COMMITMENT IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) , ) Case No. Respondent. ) ) PETITION FOR 180-DAY COMMITMENT As a mental health professional who has examined the respondent, the petitioner alleges that: 1. day commitment, the respondent: continues to be gravely disabled and there is reason to believe that the respondent's mental condition could be improved by a continued course of treatment. has attempted to inflict or has inflicted serious bodily harm upon himself/herself or another since his/her acceptance for evaluation. was committed initially as a result of conduct in which he/she attempted or inflicted serious bodily harm upon himself/herself or another. demonstrates a current intent to carry out plans of serious harm to himself/herself or another. . The respondent is mentally ill because: . As a result of being mentally ill, the respondent is: Likely to cause serious harm to himself or herself because: Likely to cause serious harm to others because: means a person who (A) poses a substantial risk of bodily harm to that person's self, as manifested by recent behavior causing, attempting, or threatening that harm; (B) poses a substantial risk of harm to others as manifested by recent behavior causing, attempting, or threatening harm, and is likely in the near future to cause physical injury, physical ab use, or substantial property damage to another person; or (C) manifests a current intent to carry out plans of serious harm to that person's self or another. (AS 47.30.915) Mental illness ability to exercise conscious control of their actions or ability to perceive reality or to reason or understand; mental retardation, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, although persons suffering fro m these conditions may also be suffering from mental illness. (AS 47.30.915) American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 2 AS 47.30.770 MC-120 (3/19)(cs) PETITION FOR 180-DAY COMMITMENT Gravely disabled under AS 47.30.915(7)(A) AS 47.30.915(7)(B) and their mental condition could improve with treatment because: 4.Commitment in a treatment facility is appropriate because evaluation staff haveconsidered but not found any less restrictive alternative that would adequately protect5. is an appropriate treatment facility for the respondent's condition and has agreed to accept the respondent. The evaluation staff has considered, but has not found, any less restrictive alternatives available that would adequately protect the respondent or others. 6.The respondent has received appropriate and adequate care and treatment duringhis/her day commitment. 7.The respondent has been advised of the need for, but has not accepted, voluntarytreatment.8.The following persons are prospective witnesses, some or all of whom will be asked totestify in favor of the commitment of the respondent at the hearing: 9.Additional Information: The petitioner respectfully requests the court to commit the respondent to the above-named treatment facility for not more than 180 days. Date Signature of Professional In Charge or their Designee Print Name and Title " Gravely disabled " means a condition in which a person as a result of mental illness (A) is in danger of physical harm arising from such complete neglect of basic needs for food, clothing, shelter, or personal safety as to render serious accident, illness, or death highly probable if care by another is not taken [AS 47.30.915(7)(A)]; or (B) will, if not treated, suffer o r continue to suffer severe and abnor mal mental, emotional, or physical distress, and this distress is associated with significant impairment of judgment, reason, or behavior causing a substantial deterioration of the person's previous ability to function independently. [AS 47.30.915(7)(B)] Note : In Wetherhorn v. Alaska Psychiatric Institute , 156 P.3d 371 (Alaska 2007), the (AS 47.30.915) " Least restrictive alternative " means mental health treatment facilities and conditions of treatment that (A) are no more harsh, hazardous, or intrusive than necessary to achieve the treatment objectives of the patient; and (B) involve no restrictions on physical movement nor supervise d residence or inpatient care except as reasonably necessary for the administration of treatment or the protection of the patient or others from physical injury. (AS 47.30.915) American LegalNet, Inc. www.FormsWorkFlow.com