Page 1 of 4 MC-100 (5/19)(cs) PETITION FOR ORDER AUTHORIZING HOSPITALIZATION FOR EVALUATION AS 47.30.700; .710 This is Not a Court Order IN THE SUPERIOR COURT FOR THE STATE OF ALASKA AT In the Matter of the Necessity ) for the Hospitalization of: ) ) , ) Case No. Respondent. ) Date of Birth: ) PETITION FOR ORDER AUTHORIZING ) HOSPITALIZATION FOR EVALUATION Petitioner, , asks the court to enter an order granting this Petition for Order Authorizing Hospitalization for Evaluation, and states as follows: 1. I read the warning notice on page 4 of this petition. 2. I am a (check all that apply): Psychiatrist Counselor Physician Social Worker Psych. RN, MS Psychologist or Psychological Associate Therapist Other Mental Health Professional* Family Member (state relationship) Other Interested Person (explain interest) Respondent has a guardian Yes No Unknown Respondent is a minor Yes No Unknown Guardian or parent contact information is as follows: Name: Relationship: Address: Phone: (cell) Email: 4. : (home, hospital, assisted living facility, etc.): Respondent arrived on (date): at am pm. Phone number respondent can be reached, if different than above: "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 psychologica l 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 therapi st 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 fi eld 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. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 4 MC-100 (5/19)(cs) PETITION FOR ORDER AUTHORIZING HOSPITALIZATION FOR EVALUATION AS 47.30.700; .710 This is Not a Court Order Mental illness ability to exercise conscious control of their actions or ability to perceive reality or to reason or understand; intellectual disability, developmental disability, epilepsy, drug addiction, and alcoholism do not per se constitute mental illness, altho ugh persons suffering from these conditions may als o be suffering from mental illness. (AS 47.30.915) 5.Basis for this Petition:a.For the following reasons, I believe that the respondent is mentally ill: b.The respondent has previously been diagnosed with a specific mental illness by ahealth care professional: Yes No Unknown. If yes, please provide information about the diagnosis such as the date(s) ofdiagnosis, any medications prescribed, prior treatment and/or prior hospitalizations: c.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: Gravely disabled under AS 47.30.915(9)(A) AS 47.30.915(9)(B) and their mental condition could improve with treatment because: means a person who (A) poses a substantial risk of bodily harm to that person's self, as manifested by r ecent 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 abu se, 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) " 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 accide nt, illness, or death highly probable if care by another is not taken [AS 47.30.915(9)(A)]; or (B) will, if not t reated, suffer or continue to suffer severe and abnormal mental, emotional, or physical distress, and this distress is associated with signific ant impairment of judgment, reason, or behavior causing a substantial deterioration of the person's previous abil ity to function independently. [AS 47.30.915(9)(B)] Note : In Wetherhorn v. Alaska Psychiatric Institute , 156 P.3d 371 (Alaska 2007), the y so (AS 47.30.915) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 4 MC-100 (5/19)(cs) PETITION FOR ORDER AUTHORIZING HOSPITALIZATION FOR EVALUATION AS 47.30.700; .710 This is Not a Court Order 6. Persons Who Have Personal Knowledge of the Above Facts Name Address Phone Yes No I have spoken with one or more of the above persons about the in gathering information before filing this petition. 7.Other Pending Court Cases Involving the Respondent (list case description and number): **MENTAL HEALTH PROFESSIONALS MUST COMPLETE THE FOLLOWING TWO SECTIONS** 8.Evaluation of Respondent by Mental Health Professional: a.I have interviewed the respondent. Yes No If yes, date and time of most recent interview: am pm. b.The respondent is in custody for an emergency evaluation. Yes No If yes, a completed MC-105, Notice of Emergency Detention and Application for Evaluation MUST BE ATTACHED to this petition. c.If the respondent is a minor or has a guardian: 1.Have the parents and/or guardian been advised that this petition is being filed? Yes No If yes, please explain how and when the parents and/or guardian were advised: 2.Have the parents and/or guardian stated they support the filing of this petition? Yes No 3.Please provide any additional information that might be helpful to the court forpurposes of contacting the parents: 9.Transportation of Respondent: a.The respondent has has not been medically cleared for transportation. b.The petitioner confirmed that the following facility or facilities have the capacitywithin the next 24 hours to accept the respondent: Alaska Psychiatric Institute PeaceHealth Ketchikan Medical Center Bartlett Regional Hospital Yukon-Kuskokwim Delta Regional Hospital Fairbanks Memorial Hospital c.The following transportation service is available to deliver the respondent to thefacility within 24 hours(s): American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 4 MC-100 (5/19)(cs) PETITION FOR ORDER AUTHORIZING HOSPITALIZATION FOR EVALUATION AS 47.30.700; .710 This is Not a Court Order Date Petitioner's Signature Print Name of Petitioner Petitioner's Mailing Address Phone Fax Email Address* Facility/Agency (if petitioning on its behalf) * I authorize the court to email me court documents in this case to the email address above. 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 , Alaska on (date) . Clerk of Court, Notary Public or other person (SEAL) 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 pe