ATTORNEY OR PETITIONER WITHOUT ATTORNEY (Name and Address): FOR COURT USE ONLY TELEPHONE NO.: PETITIONER'S BIRTH DATE: SUPERIOR COURT OF CALIFORNIA, COUNTY OF IN THE MATTER OF (NAME): CASE NUMBER: Petitioner PETITION FOR WRIT OF HABEAS CORPUS — LPS Act 1. Petitioner is being unlawfully restrained of liberty at (specify name of treatment facility): by (specify name of agency and treating psychiatrist): 2. Petitioner was admitted to the treatment facility on (date): W & I § 5250 (14-day certification) W & I § 5150 (72-hour hold) W & I § 5270.15 (30-day cert.) W & I § 5300 (180-day post-certification) W & I § 5350 (conservatorship) Other (specify): and is currently being held pursuant to W & I § 5260 (2d 14-day certification) W & I § 5352.1 (temporary conservatorship) 3. Check at least one box: Petitioner is illegally confined for the following reason: a. b. Petitioner has been denied the following rights without good cause (Welfare and Institutions Code sections 5325, 5325.1, and 5326): 4. Petitioner requests that this court (check all that apply): Issue a Writ of Habeas Corpus to the director of the facility named in item 1, commanding that the petitioner be brought a. before this court at a specified time and place. Order the facility to release petitioner from restraint. b. c. Order that all rights to which petitioner is entitled as a patient be observed. d. Grant such other relief as this court deems appropriate. I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. Date: .............................................. (TYPE OR PRINT NAME) Form Approved by the Judicial Council of California MC-265 [New January 1, 1994] (SIGNATURE OF PETITIONER OR PERSON REQUESTING WRIT ON PETITIONER'S BEHALF) PETITION FOR WRIT OF HABEAS CORPUS — LPS Act (Mental Health) 2001 © American LegalNet, Inc.