MH 006 (Rev. 07/18) PETITION AND DECLARATION OF SERVICE REGARDING Page 1 of 4 Mandatory Form CAPACITY TO GIVE INFORMED CONSENT TO MEDICATION Hospital: (Name) Unit: (Name or Number) Interpreter Required: NO YES (Language) SUPERIOR COURT OF CALIFORNIA COUNTY OF LOS ANGELES Petitioner, , declares that: (Please type/print Treating Physician222s Name) 1. On , I evaluated (Date) (Patient's Name) at. (Hospital Name) 2. This patient is currently being held at the above facility under Welfare and Institutions Code Section(s): 5150 (72 hour hold) 5250 (14 day hold) 5260 (additional 14 day hold) 5270.15 (additional intensive treatment 30 day hold) 5300 (180 day post certification) 3. This patient is presently showing symptoms of a mental disorder known as: These symptoms are: In the Matter of ) (RIESE PETITION) ) PETITION AND DECLARATION OF ) SERVICE R EGARDING CAPACITY TO GIVE ) INFORMED CONSENT TO MEDICATION ) WIC 247 5332(b) ) (Patient222s Name) ) BY FAX American LegalNet, Inc. www.FormsWorkFlow.com MH 006 (Rev. 07/18) PETITION AND DECLARATION OF SERVICE REGARDING Page 2 of 4 Mandatory Form CAPACITY TO GIVE INFORMED CONSENT TO MEDICATION 4. In my professional judgment the patient would benefit from the administration of the following classes of psychiatric medications: . 5. I declare further that I have explained or attempted to explain to the patient the risks, benefits, possible side effects and treatment alternatives as described in Welfare and Institutions Code Section 5213(b) and to obtain the patient's consent to receive medication: (Insert dates and description of each explanation or attempted explanation and the dates these were charted) . 6. The patient's responses to these efforts were the following: (Verbatim, if possible) . 7. It is my professional opinion that the patient is not able to give informed consent to the recommended medication because: A) The patient is aware is not aware of his/her mental disorder; (Explain) American LegalNet, Inc. www.FormsWorkFlow.com MH 006 (Rev. 07/18) PETITION AND DECLARATION OF SERVICE REGARDING Page 3 of 4 Mandatory Form CAPACITY TO GIVE INFORMED CONSENT TO MEDICATION B) The patient is able is not able to understand the risks or benefits of medication or alternative treatments; (Explain) . C) The patient [ ] is able [ ] is not able rationally to understand and evaluate information regarding informed consent, and otherwise participate in the treatment decision; (Explain) . 8. Medication must be administered in order to alleviate the acuteness of the patient's current symptomatology. 9. It is alleged on information and belief that the patient is required to have an advocate/legal counsel appointed and is unable to retain such services. WHEREFORE, Petitioner prays that: 1. An advocate be appointed to represent the patient in the medication capacity hearing. The advocate may be an attorney privately retained by the patient or an employee of the Los Angeles County Department of Mental Health attached to the Patient's Rights Office; 2. The Court issue an order finding that the patient is incapable of giving informed consent during the patient's commitment under the aforementioned applicable Welfare and Institutions Code Sections. 3. For all other further and proper relief. American LegalNet, Inc. www.FormsWorkFlow.com MH 006 (Rev. 07/18) PETITION AND DECLARATION OF SERVICE REGARDING Page 4 of 4 Mandatory Form CAPACITY TO GIVE INFORMED CONSENT TO MEDICATION I DECLARE THE FOREGOING TO BE TRUE UNDER PENALTY OF PERJURY AND THAT THIS DECLARATION IS EXECUTED AT , THIS (City) (Day) OF , . (Month) (Year) // Excluding the date the petition is faxed, I am available to present at the hearing at the hospital as follows: Day: Date: Time: Day: Date: Time: Day: Date: Time: NOTE: All dates above must be within THREE DAYS of the date of filing this Petition, as required by WIC 247 5334(a). Times must be specified as a.m. or p.m. (Hearings are held on Monday through Friday between 9:30 a.m. and 5:00 p.m.) Respectfully submitted, By (Signature of Treating Physician) // // // // NOTICE: UNDER PENALTY OF PERJURY, I DECLARE THAT I HAVE SERVED A COPY OF THIS CAPACITY PETITION OR NOTICE OF THE FILING OF THIS CAPACITY PETITION TO THE ABOVE NAMED PATIENT ON THIS DATE. By (Person designated by the hospital to serve the patient) (Date) American LegalNet, Inc. www.FormsWorkFlow.com