JC-E-312 Mandatory JC-E-312 Adopted: 01/01/19 APPLICATION FOR APPROVAL OF A MINOR222S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT (Welfare & Institutions Code 247 6552) Page 1 of 2 A p plicati o n s u b m itted by ( N am e and A d d re s s) Name: Street Address: City, State: Telephone Number: FOR COURT USE ONLY S U PE RI O R COU RT O F C A LIFO R NIA , C OU N T Y O F SAC R A M E N TO Street Address: 3341 Power Inn Road City and Zip Code: Sacramento CA 95826 Bra n ch Na m e: SITTING A S THE J UV E N I LE C O URT NAME OF CHILD/MINOR: APPLICATION FOR APPROVAL OF A MINOR222S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT ( Welfare & Institutions Code 247 6552) CASE NUMBER: 1. My name is . I am years old; and was bornon . 2. My attorney is . 3. I understand that I was placed in this psychiatric facility because it is the opinion of the professionaloffice staff that, as a result of a mental disorder, I am: (check applicable boxes) Dangerous to myself.Dangerous to others.Gravely disabled. 4. I have discussed with my attorney my rights, which are as follows:My right to object to being admitted to a psychiatric facility.My right to a hearing or writ if the professional staff decide that I need continued treatment beyond72 hours.My right to decide on my own that I need treatment from the professional staff. 5. I understand these rights, and after talking with my attorney, I do apply to the Juvenile Court forapproval of my decision that I receive treatment from the professional staff as my own voluntary decision. 6. I understand that the treatment I receive may include medications, which may continue when Ileave the hospital. 7. I understand that I can revoke (that is, stop or end) my decision to receive voluntary inpatient treatment I may do so by telling my attorney to set a hearing before a Juvenile Court Judge. IF THIS APPLICATION IS FOR ADMISSION TO A COMMUNITY TREATMENT FACILITY: 8. I wish to be voluntarily admitted to a Community Treatment Facility (CTF). I understand that a CTFprovides mental health treatment in a locked residential environment and that my rights as described above still apply. Date: Minor TO THE FACILITY: Rule 7.18 of the Sacramento Superior Court Local Rules provides that this application, signed by the minor and the attorney, shall constitute a sufficient basis for the hospital or facility to accept the minor as a voluntary inpatient, pending approval of the application by the Juvenile Court. American LegalNet, Inc. www.FormsWorkFlow.com NAME OF MINOR/CHILD: CASE NUMBER Mandatory JC-E-312 Adopted: 01/01/19 APPLICATION FOR APPROVAL OF A MINOR222S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT (Welfare & Institutions Code 247 6552) Page 2 of 2 ATTORNEY CERTIFICATION I certify that I have reviewed this application with the minor, and have advised the minor of the effects of applying for voluntary inpatient treatment. The minor made a free, voluntary and intelligent decision to forgo his/her rights at the time, and did make an informed request to receive voluntary inpatient treatment. The minor also understands that medication may be a part of the treatment, even after discharge from the hospital. I have no objection to the minor222s request that the Juvenile Court approve the minor222s decision to receive inpatient treatment. Date: Attorney American LegalNet, Inc. www.FormsWorkFlow.com