IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity for the Hospitalization of: , Respondent. Date of Birth: ) ) ) ) ) ) ) ) Case No. PETITION FOR INVOLUNTARY COMMITMENT FOR EVALUATION Petitioner, , asks the court to enter an order granting this Petition for Involuntary Commitment for Evaluation, and states as follows: 1. I read the warning notice on page 3 of this petition. 2. I am a (check all that apply): Psychiatrist Physician Psych. RN, MS Therapist Social Worker Counselor Psychologist or Psychological Associate Other Mental Health Professional Family Member Other Interested Person "Mental health professional" means a psychiatrist or physician licensed by the State Medical Board to practice in this state or employed by the federal government; a clinical psychologist licensed by the state Board of Psychologist and Psychological Associate Examiners; a psychological associate trained in clinical psychology and licensed by the Board of Psychologist and Psychological Associate Examiners; a registered nurse with a master's degree in psychiatric nursing, licensed by the State Board of Nursing; a marital & family therapist licensed by the Board of Marital and Family Therapy; a professional counselor licensed by the Board of Professional Counselors; a clinical social worker licensed by the Board of Social Work Examiners; and a person who (A) has a master's degree in the field of mental health; (B) has at least 12 months of post-masters working experience in the field of mental illness; and (C) is working under the supervision of a type of licensee listed in this paragraph. 3. Respondent is currently located at (for example, home, hospital, assisted living facility): Respondent arrived on (date) 4. 5. at am pm. Respondent is a minor. Parents/guardian contact information is as follows: Name(s): Address: Phone: A completed MC-105, Notice of Emergency Detention and Application for Evaluation is attached is not attached. (The MC-105 may only be signed by a peace officer, psychiatrist, doctor, or clinical psychologist. See AS 47.30.705.) This is Not a Court Order Page 1 of 3 MC-100 (3/12)(cs) PETITION FOR INVOLUNTARY COMMITMENT FOR EVALUATION AS 47.30.700; .710 American LegalNet, Inc. www.FormsWorkFlow.com 6. Other pending court cases involving the respondent include (list case description and case number): 7. For the following reasons, I believe that the respondent is mentally ill: Specific mental illness: f “Mental illness” means an organic, mental, or emotional impairment that has substantial adverse effects on a i person’s ability to exercise conscious control of the 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, calthough persons suffering from these conditions may also be suffering from mental illness. (AS 47.30.915) 8. For the following reasons, I believe that as a result of that mental illness, the respondent is gravely disabled or likely to cause serious harm to himself/herself or others: "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 or continue to suffer severe and abnormal 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 Alaska Supreme Court “concluded that AS 47.30.915(7)(B) is constitutional if construed to require a level of incapacity so substantial that the respondent is not ‘capable of surviving safely in freedom.’” “Likely to cause serious harm" 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 abuse, 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. 9. Persons who have personal knowledge of the above facts are: Name Address Phone This is Not a Court Order Page 2 of 3 MC-100 (3/12)(cs) PETITION FOR INVOLUNTARY COMMITMENT FOR EVALUATION AS 47.30.700; .710 American LegalNet, Inc. www.FormsWorkFlow.com 10. For healthcare professionals only: The following facility or facilities currently have capacity to accept persons committed for emergency examination and evaluation: The following transport service is available to deliver the respondent to the facility: Date Petitioner's Signature Print Name of Petitioner Petitioner's Address Phone: Fax: Verification or Certification Verification. [Sign in front of a notary or court clerk. If no notary or court clerk is available, or you do not have ID required by a notary or other official, sign the certification section below.] Petitioner says on oath or affirms that petitioner has read this petition and believes that all statements made in the petition are true. Subscribed and sworn to or affirmed before me at (date) . (SEAL) , Alaska on Clerk of Court, Notary Public or other person authorized to administer oaths. My commission expires: Certification. [Complete this certificate if no notary or other official is available, or if you do not have the required identification.] Petitioner certifies that all information in this petition is true, and a notary public or other official empowered to administer oaths is not available to administer an oath, or petitioner does not have the ID required by a notary or other official. Petitioner's Signature Warning Notice A person acting in good faith upon either actual knowledge or reliable information who applies for evaluation or treatment of another person under AS 47.30.700-47.30.915 is not subject to civil or criminal liability. [AS 47.30.815(a)] A person who willfully initiates an involuntary commitment procedure under AS 47.30.700 without having good cause to believe that the other person is suffering from a mental illness and as a result is gravely disabled or likely to cause serious harm to self or others, is guilty of a felony. [AS 47.30.815(c)] This is Not a Court Order Page 3 of 3 MC-100 (3/12)(cs) PETITION FOR INVOLUNTARY COMMITMENT FOR EVALUATION AS 47.30.700; .710 American LegalNet, Inc. www.FormsWorkFlow.com