IN THE CIRCUIT COURT OF THE SECOND JUDICIAL CIRCUIT IN AND FOR LEON 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 court order for the Print Name of Petitioner 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 a: (Occupation) ___________________________________________ Work Phone: (_______) ___________ Work Street Address: __________________________________________________ City ____________ ST _____ Zip _______ c. 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: ____________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ 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, battery, child abuse or neglect, Baker Act, etc. as described:______________________________________________________________________________________________ ______________________________________________________________________________________________________ CONTINUED OVER American LegalNet, Inc. www.USCourtForms.com Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (Page 2) 4. (Check the one box that applies) a. I or a family member are not now, and have not in the past, been involved in a court case with the PERSON. b. I or a family member am now, or was, involved in a court case with the PERSON. This case is/was a ___________________________________________________________ in ________________________________ Type of Case When Explain:__________________________________________________________________________________________ _________________________________________________________________________________________________ 5. I am on good terms with the PERSON at the present time. (Check one box) Yes No If "no", please explain: _________________________________________________________________________________________________ _________________________________________________________________________________________________ 6. I have known the PERSON for ___________________________ (how long). a. The PERSON has only recently displayed unusual kinds of behavior. b. The PERSON has, over a period of time, always acted in a strange manner. c. 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.USCourtForms.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 mental health care: __________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ These steps did not work because: __________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 12. I believe that the PERSON is unable to determine for himself/herself, why the examination is necessary because: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 13. I believe that the PERSON has a mental illness which will keep the PERSON from being able to meet the ordinary demands of living because: ________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 14. I believe that without care or treatment, the PERSON is likely to suffer from neglect or refuse to care for himself/ herself, because: ______________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 15. I believe that this lack of care or neglect will lead to the PERSON hurting himself or herself because: ______________________________________________________________________________________________ ______________________________________________________________________________________________ ______________________________________________________________________________________________ 16. Can family or close friends now provide enough care to avoid harm to the PERSON? Yes No, If not, why? _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ CONTINUED OVER American LegalNet, Inc. www.USCourtForms.com Petition and Affidavit Seeking Ex Parte Order Requiring Involuntary Examination (Page 4) Provide the following identifying information about the person (if known) if it is determined necessary to take the person into custody for examination: County of Residence: Sex : Male Social Security No.: Female Race: Height: Date of Birth: Attach a picture of the PERSON if possible. Weight: Hair Color: Does the PERSON have access to any weapons? Is the PERSON violent now? No Yes Picture attached: No Yes No Yes Eye Color: If yes, describe: Has the person been violent in the recent past? Does the PERSON have any pending criminal charges against him/her? No Yes No Yes If Yes, Describe: If yes, describe: GUARDIANSHIP: 1) Does the PERSON have a legal guardian? No Yes 2) Is there a pending petition to determine the PERSON’s capacity and for the appointment of a guardian? No If YES to either of the above, provide the name, address and phone number of the current or proposed guardian. Yes Name: Phone: (___________) _____________________________ Address: City: Zip: ____________ _________________________________________________________________________________________________________________________ PHYSICIAN: Name: MEDICATIONS: Phone: ( ) Provide name of medications if known. CASE MANAGEMENT: Provide name and phone number of case manager or case management agency, if known. I understand that this sworn statement is given under oath and will be treated as though it was made before a judge in a court of law. I understand that any information in this sworn statement which is not to the best of my knowledge and done in good faith may expose me to a penalty for perjury and other possible penalties under the statutes of the State of Florida. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it are true. Signature of Affiant/Petitioner: ________________________________________________ SWORN TO AND SUBSCRIBED before me OR SWORN TO AND SUBSCRIBED before me this __________ day of ________________________, ______________ Day Month Year this __________ day of ________________________, ______________ Day Month Year by _____________________________________ who is personally known Clerk of Circuit Court to me or presented ________________________________ as identification. _____________________________ County, Florida ___________________________________________________________ Notary Public - State of Florida By: _______________________________________________________ Deputy Clerk My Commission expires: Date_____________________ A copy of the petition(s) must be attached to an Ex Parte Order for Involuntary Examination and accompany the person to the nearest receiving facility. See s. 394.463, Florida Statutes CF-MH 3002, Feb 05 (obsoletes previous editions) (Recommended Form) BAKER ACT American LegalNet, Inc. www.USCourtForms.com