IN THE CIRCUIT COURT OF THE do& , INAND FOR JUDICIAL CIRCUIT, b COUNTY, FLORIDA IN RE: CASE NO.: Respondent: I Petition and Affidavit Seeking Involuntary Substance Abuse Assessment and Stabilization being duly sworn, am filing this sworn statement requesting a court order (Print Name of Petitioner) for the involuntary assessment of (hereinafter referred to as PERSON). (Print Name of Person 1 , The PERSON is 18 years of age or older? yes or no Age 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 hospital or licensed substance abuse facility for assessment and stabilization. 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 ResidenceAddress and Phone Number) Phone: ) Street Address: City ST Zip b. The PERSON lives at, or may be found at, the following address(es): Street Address: City Street Address: City 2. 1 have the following relationship with the PERSON: 3. 1 am on good terms with the PERSON at the present time. (Check one box) Yes No If "no", please explain: 4. (Check the box that applies) a. I or a family membern have or have not previously made allegations to law enforcement involving (Date) such as domestic violence, trespassing, battery, child abuse or this PERSON on neglect, Baker Act, etc. as described: b. This PERSON or my family on has or has not previously made allegations to law enforcement about me (Date) such as domestic violence, trespassing, battery, child abuse or neglect, Baker Act, etc. as described: Marchman Act Handbook Page 265 American LegalNet, Inc. www.FormsWorkflow.com Petition and Affidavit Seeking Involuntary Substance Abuse Assessment and Stabilization Page 2 c. This PERSON O h a s or q has not previously or currently criminalldelinquency charges. 5. (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 islwas a in (type of case) (when) 6. 1 have known the PERSON for (how long). a. The PERSON has only recently displayed behavior related to substance abuse. b. The PERSON has, over a period of time, had a substance abuse problem. Specify how long: COMPLETE 'THE FOLLOWING ONLY IF THE SECTION APPLIES TO THIS CASE: 7. 1 believe that the PERSON is substance abuse impaired (defined in the law as the use of alcoholic beverages or any psychoactive or mood-altering substance in such a manner as to induce mental, emotional, or physical problems and cause socially dysfunctional behavior): 8. 1 believe that the PERSON has lost the power of self-control with respect to substance use because: 9. 1 have seen the following behavior, which causes me to believe that the that the PERSON has inflicted, or threatened or attempted to inflict, or unless admitted for assessment is likely to inflict, physical harm on himself or herself or someone else On at approximately am pm, I saw the PERSON: Date Time 10. Other similar behavior I have personally seen is as follows: 11. I believe the PERSON is in need of substance abuse services because his or her judgment has been so impaired that he or she is incapable of appreciating his or her need for such services and of making a rational decision about services because (a mere refusal to receive services is not enough to constitute lack of judgment): Marchman Act Handbook Page 266 American LegalNet, Inc. www.FormsWorkflow.com Petition and Affidavit Seeking Involuntary Substance Abuse Assessment and Stabilization page 3 12. To my knowledge or belief, I do not believe these actions were a result of mental illness, retardation, developmental disability, or conditions resulting from antisocial behavior. CHECK AND/OR ANSWER APPLICABLE SECTIONS 13. q a. I have attempted to get the PERSON to agree to seek assistance for a substance abuse problem(s) as follows: b. I did not try to get the PERSON to agree to a voluntary assessment or treatment because: - - - a c. 'The PERSON refused a voluntary assessment or treatment because: 14. 0 have made arrangements for the PERSON to be admitted to 1 Facility located at for voluntary assessment and stabilization. 15. The name of the PERSON's attorney is (if any): 16. PERSON q can Ocannot to represent the PERSON. afford an attorney. If not, petitioner requests the court to appoint an attorney Provide the following identifying information about the person (if known) i f it is determined necessary t o take the person into custody for examination: Sex : q Male [7 Yes q Female Attach a picture of the PERSON if possible -Picture attached: [7 No Race: Height: Weight: Does the PERSON have access to any weapons? Is the PERSON violent now? If Yes, Describe: [7 No q Yes Hair Color: q No q Yes Eye Color: If yes, describe: Has the PERSON t been violent in the recent past? Does the PERSON have any pending criminal charges against himlher? [7 No [7 Yes [7 No q Yes If yes, describe: Yes 1) Does the PERSON have a legal guardian? q No 2) Is there a pending petition to determine the PERSON'Scapacity and to appoint a guardian? q No Yes If YES to either of the above, provide the name, address and phone number of the current or proposed guardian. Name: Phone: ( ) Address: City: Zip: Phone: ( ) Physician's Name: : Provide name of medications, if known. I understand that this sworn statement is given under oath and will be treated as though it was made before a judge i n 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, Ideclare that Ihave read the foregoing document and that the facts stated in it are true. Marchrnan Act Handbook Page 267 American LegalNet, Inc. www.FormsWorkflow.com Petition and Affidavit Seeking Involuntary Substance Abuse Assessment and Stabilization page 4 Signature of AffiantIPetitioner: OR SWORN TO AND SUBSCRIBED before me this day of SWORN TO AND SUBSCRIBED before me this by Florida personally known to me or presented who is as identification. day of clerk of Circuit Court County, By: Deputy Clerk - - Notary Public - State of Florida My Commission expires: Date A copy of ,this petition must be attached to an Order for Involuntary Substance Abuse Assessment and Stabilization and accompany the PERSON to a licensed hospital or substance abuse facility that has agreed to accept the PERSON. Page 4 or 4 FORM MA-7 See s. 397, Florida Statutes MARCHMAN ACT Marchman Act Handbook Page 268 American LegalNet, Inc. www.FormsWorkflow.com