Name of Party seeking Application IN THE FAMILY COURT OF THE SECOND CIRCUIT STATE OF HAWAI`I IN THE INTEREST OF RESPONDENT-SUBJECT SUBJECT222S INFORMATION:002 ) FC-M NO. ) ) APPLICATION FOR EMERGENCY ) EXAMINATION AND TREATMENT ) ) ) ) ) (NAME) (CURRENT ADDRESS) (PERMANENT ADDRESS) (PHONE NO) (PHONE NO) (BIRTHDATE OR AGE) (SEX) (MARITAL STATUS) If subject is a minor, parent222s or guardian222s or custodian222s Name: Address: Phone No: In accordance with the Americans with Disabilities Act and other applicable state and federal laws, if you require a reasonable accommodation for002 a disability, please contact the ADA Coordinator at the Family Court Administration Office at PHONE NO. 244-2700, FAX 244-2704 or email002 adarequest@courts.hawaii.gov at least ten (10) working days prior to your hearing or appointment date. For all Civil related matters, please call002 244-2706 or visit the Service Center at 2145 Main Street, Room 141, Wailuku, HI 96793002 American LegalNet, Inc. www.FormsWorkFlow.com page 2 Continued Subject222s Spouse, Relative or Friend, other than applicant:002 Name: 002 Address:003 Phone No: 002 Pursuant to HRS Chapter 334, the undersigned applies for emergency examination and treatment of the subject identified above and alleges as follows: (1)003 That he/she is a: [ ] licensed physician [ ] attorney [ ] member of the clergy [ ] health or social service professional [ ] state of county employee in the course of his/her employment (2)003 That there is probable cause to believe the above-named person is: [ ] mentally ill [ ] suffering from substance abuse, and is imminently dangerous to: [ ] self [ ] others002 and is in need of care and/or treatment.002 (3) That circumstances and reasons for his/her belief are alleged as follows or on the attached: (Include date, time and place of activity, whether based on first-hand knowledge or information of another and names and addresses of witnesses, if any.) American LegalNet, Inc. www.FormsWorkFlow.com page 3 Continued The applicant asks the court to enter a written order directing any police officer or other suitable person to take the above-named subject into custody and deliver him to: [ ] Queen222s Medical Center and/or Hawai`i State Hospital [ ] Maui Memorial Medical Center Emergency Room for admission to the Molokini Unit for emergency examination and treatment. I HEREBY CERTIFY UNDER PENALTY OF PERJURY THAT THE ALLEGATIONS MADE HEREIN ARE TRUE OF MY OWN KNOWLEDGE EXCEPT AS TO MATTERS STATED UPON INFORMATION AND BELIEF WHICH I BELIEVE ARE TRUE ALSO. (Date) (Applicant222s Signature) (Applicant222s Name) (Address) (City, State, ZipCode) (Phone No) American LegalNet, Inc. www.FormsWorkFlow.com