Print Form Clear Form Order/Detention, Examination, Evaluation IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION IN RE THE MATTER OF (Rev. 6/01/11) CCCO 0085 A ______________________________________________________ Asserted to be a person subject to Involuntary Hospitalization Respondent ________ COMH _________ ORDER FOR EXAMINATION ORDER FOR DETENTION AND EXAMINATION DENIAL ORDER This matter coming on for hearing on the Petition of: _______________________________________ seeking an Examination Pursuant to 405 ILCS 5/3-704 or an Emergency Admission Pursuant to 405 ILCS 5/4-400 et seq. and the Court being fully advised finds as follows: 1. That no one certificate certifying that the Respondent is subject to involuntary admission has been filed. 2. a. That the Respondent is in need of an Examination b. That the Respondent is in need of Detention and Examination IT IS ORDERED THAT: The Petition for writ is DENIED Petition is GRANTED and 1. ____________________________________________ shall submit to an examination by either a physician, clinical psychologist, or a qualified examiner and a psychiatrist within 24 hours of arrival at _____________________________________________. (Name of hospital) 2. a. The Respondent is allowed to remain at his/her place of residence until the time of the examination b. The Peace Officer of _______________________________________________________________________ (City, Village, Town, County) is commanded to take custody of ______________________________________________________________ (Respondent's name and address) and IMMEDIATELY take him/her to __________________________________________________________ (Name and address of local mental health facility) _______________________________________________ for detention and examination pursuant to this Order AND as required by 405 ILCS 3-705 serve him/her with a copy of the Petition, Order and Notice of Rights. 3. A qualified staff person (as defined above) is hereby appointed to examine______________________________ (Name of Respondent) and report to this Court within 24 hours of the Respondent's arrival at the mental health facility. (1 of 3 Pages) (Rev. 6/01/11) CCCO 0085 B 4. NOTICE TO FACILITY: If the Facility Director accepts a request by the Respondent to be admitted to your facility as an informal or voluntary recipient, you are required by 405 ILCS 5/3-801 to notify the Petitioner: ___________________________________ (Name) _________________________________________________ (Address) ______________________________________ of that request and their right to appear in Court and object to the (Phone Number) dismissal of this proceeding. (Check Box if Petitioner has requested Notice in the Petition Filed with the Court). 5. The Clerk of Court shall certify this Order. 6. This matter is set for Case Management/Scheduling Conference on _________________________, __________ at 11:00 a.m. in Courtroom 1703, Richard J. Daley Center, Chicago, Illinois 60602. ENTERED: ____________________________________________ Judge Judge's No. Date of Issuance: ____________________, _________ Time of Issuance: _____________________________ THIS ORDER IS ONLY IN EFFECT FOR 96 HOURS AFTER IT IS ISSUED. SEE NEXT PAGE FOR RETURN (2 of 3 Pages) (Rev. 6/01/11) CCCO 0085 C RETURN On _______________________________, __________, at ______________ (a.m./p.m.) I took custody of ____________________________________________________________, and served him/her with a copy of the Petition, this Order, and a Statement of Rights, and brought him/her to __________________________________________________ as commanded ______________________________, __________, (Date) ____________________________________________ (Signature) TO BE COMPLETED AT THE FACILITY (if applicable) On _______________________________, __________, at ________________ (a.m./p.m.) ________________________________________________ was received at this facility together with his/her personal property. Facility ___________________________________________ Staff Signature _____________________________________ Title __________________________________________ Facility Director ___________________________________ DOROTHY BROWN, CLERK OF THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS (3 of 3 Pages)