IN THE CIRCUIT COURT OF THE TWENTIETH JUDICIAL CIRCUIT IN AND FOR LEE COUNTY, FLORIDA IN RE: __________________ CASE NO.: ______________ PETITION AND AFFIDAVIT SEEKING EX PARTE ORDER REQUIRING INVOLUNTARY EXAMINATION I, ___________________________________________, being duly sworn, am filing this sworn statement requesting a Print Name of Petitioner court order for the involuntary examination of ______________________________ (hereinafter referred to as PERSON). Print Name of Person This petition and affidavit will be included in the PERSON's clinical record and may be viewed by the PERSON. I understand that by filling out this form, the PERSON may be taken by law enforcement to a mental health facility for an examination. I SWEAR that the answers to the following questions are given honestly, in good faith, and to the best of my knowledge. 1. a. I live at: (Print Your Full Residence Address and Phone Number) Phone: (_______) _______________________________ Street Address: _________________________________________ City _____________________ ST ______ Zip_______ b. I work as: (Occupation) ___________________________________________ Work Phone: (______) _________________ Work Street Address: ____________________________________ City _____________________ ST______ Zip_______ The PERSON lives at, or may be found at, the following address(es): Street Address: ________________________________________________________________ City __________________ Street Address: ________________________________________________________________ City __________________ Street Address: ________________________________________________________________ City __________________ 2. I have the following relationship with the PERSON: _________________________________________________________________ ___________________________________________________________________________________________________________ 3. (Check the one box that applies) a. I or a family member have or have not previously made allegations to law enforcement involving this PERSON on _______________ (Date) such as domestic violence, trespassing, battery, child abuse or neglect, Baker Act, neighborhood disputes, etc. as described: _______________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ c. b. This PERSON has or has not previously made allegations to law enforcement about me or my family on ______________ (Date) such as domestic violence, trespassing, child abuse or neglect, Baker Act, etc. as described: _________________________________________________________________________________________________ _________________________________________________________________________________________________ CONTINUED American LegalNet, Inc. www.FormsWorkFlow.com Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (Page 2) (Check the one box that applies) 4. a. b. I or a family member are not now, and have not in the past, been involved in a court case with the PERSON. I or a family member am now, or was, involved in a court case with the PERSON. This case is/was a Type of Case Explain: in When _______________________________________________________________________________________ _________________________________________________________________________________________________ 5. I am on good terms with the PERSON at the present time. (Check one box) Yes No If "no", please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. a. b. c. I have known the PERSON for ______________________________ (how long). The PERSON has only recently displayed unusual kinds of behavior. The PERSON has, over a period of time, always acted in a strange manner. The PERSON's behavior has developed over a period of time. COMPLETE THE FOLLOWING ONLY IF THE SECTION APPLIES TO THIS CASE: 7. I have seen the following behavior, which causes me to believe that there is a good chance that the PERSON will cause serious bodily harm to himself/herself or others. On _________________ at approximately _________ am pm, Date Time I saw the PERSON: ________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 8. Other similar behavior I have personally seen is as follows: ________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ 9. To my knowledge or belief, I do, I do not believe these actions were a result of retardation, developmental disability, intoxication, or conditions resulting from antisocial behavior or substance abuse impairment. CHECK AND/OR ANSWER APPLICABLE SECTIONS 10. a. I have attempted to get the PERSON to agree to seek assistance for a mental or emotional problem(s). I explained the purpose of the examination (describe when, who was present, and whether you or another person explained the need for the examination): _______________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________ b. I did not try to get the PERSON to agree to a voluntary examination because: __________________________________ ________________________________________________________________________________________________ c. The PERSON refused a voluntary examination because: ___________________________________________________ ________________________________________________________________________________________________ CONTINUED American LegalNet, Inc. www.FormsWorkFlow.com Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (Page 3) 11. The following steps were taken to get the PERSON to go to a hospital for men