ATTORNEY OR PARTY WITHOUT ATTORNEY(Name, state bar number, and address): FOR COURT USE ONLY TELEPHONE NO.: ATTORNEY FOR (Name): FAX NO.: SUPERIOR COURT OF CALIFORNIA, COUNTY OF SAN DIEGO JUVENILE COURT JUVENILE COURT, 2851 MEADOW LARK DR., SAN DIEGO, CA 92123-2792 NORTH COUNTY DIVISION, 325 S. MELROSE DR., VISTA, CA 92081-6634 SOUTH COUNTY DIVISION, 500 3RD AVE., CHULA VISTA, CA 91910-5649 EAST COUNTY DIVISION, 250 E. MAIN ST., EL CAJON, CA 92020-3941 In The Matter of A MINOR APPLICATION FOR APPROVAL OF A MINOR'S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT (W&I Code § 6552) CASE NUMBER 1. My name is ___________________________________. I am _______ years old; and was born on ______________. 2. My attorney is ___________________________________________________. 3. My attorney is not available, and ___________________________________, from has counseled me and advised me regarding this application. , 4. I understand that I was placed in this psychiatric facility because it is the opinion of the professional office staff that, as a result of a mental disorder, I am: (check applicable boxes) Dangerous to myself. Dangerous to others. Gravely disabled. 5. 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 beyond 72 hours. My right to decide on my own that I need treatment from the professional staff. 6. I understand these rights, and after talking with my attorney, I do apply to the Juvenile Court for approval of my decision that I receive treatment from the professional staff as my own voluntary decision. 7. I understand that the treatment I receive may include medications, which may continue when I leave the hospital. 8. 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: 9. I wish to be voluntarily admitted to a Community Treatment Facility (CTF). I understand that a CTF provides mental health treatment in a locked residential environment and that my rights as described above still apply. Date: Minor TO THE FACILITY: Rule 8.10.4. of the San Diego Superior Court 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. APPLICATION FOR APPROVAL OF A MINOR'S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT SDSC JUV-57(Rev. 10-06) Page one of two American LegalNet, Inc. www.FormsWorkflow.com CASE NUMBER: 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 this 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 minor's request that the Juvenile Court approve the minor's decision to receive inpatient treatment. Date: Attorney ATTORNEY REPRESENTATIVE/PATIENT ADVOCATE CERTIFICATION I certify that I have reviewed this application with the minor, and have discussed with the minor the effects of applying for voluntary inpatient treatment. The minor made a free, voluntary and intelligent decision to forgo his/her rights at this 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. Date: Attorney Representative/Patient Advocate I have no objection to the minor's request that the Juvenile Court approve the minor's decision to receive inpatient treatment. Date: Attorney ORDER 1. The Court has read and considered: a. The executed application of the minor for voluntary inpatient treatment. b. The declaration of the attending therapist. c. The treatment plan which sets forth the category of medications to be administered to the minor. d. Further evidence presented. d. Other: 2. The Court finds: a. b. c. d. e. f. g. All persons entitled to notice have received notice. No objection has been filed with the Court. The minor suffers from a mental disorder. The facility is qualified to treat the disorder. There is no other less restrictive facility available which might better address the needs of the minor. The minor has made a knowledgeable and intelligent request to receive voluntary inpatient treatment. An objection has been filed with the Court, and a hearing shall be set on the Application on at __________ o'clock, in Department __________ of the Juvenile Court. The Clerk of the Court is to notice all parties and counsel. 3. THE COURT ORDERS: a. That the minor's application is APPROVED. The minor shall receive treatment, both inpatient and outpatient, including medications, until such time as the application is properly revoked. b. That the minor's application is DENIED. The minor shall be released unless the minor may be held involuntarily under the provisions of the LPS Act. Date: Judicial Officer APPLICATION FOR APPROVAL OF A MINOR'S REQUEST FOR VOLUNTARY INPATIENT PSYCHIATRIC TREATMENT SDSC JUV-57(Rev. 10-06) Page two of two