Print Form Clear Form INSTRUCTIONS FOR COMPLETING PETITION FOR INVOLUNTARY ADMISSION TO A MENTAL HEALTH FACILITY Paragraph 1: Must be completed in all cases. Please state in your own words, but in detail, the signs and symptoms of mental illness displayed by the Respondent. Your personal observations that lead you to believe the Respondent is subject to involuntary admission should be included. It is important to include any diagnosis of mental illness, prior treatment and/or hospitalizations known to you. Describe any threats that he or she has recently made to physically harm himself or herself, or any other person; any behavior or pattern of behavior that indicate an inability of the person to provide for his or her basic needs; e.g., food, shelter, medical care without the intervention of family or friends. If the individual has a history of deteriorating mental health due to their lack of understanding of the disease process and you reasonably expect such person will deteriorate mentally, emotionally or both to an extent that will render him or her incapable of providing for basic needs without the assistance of family or friends, please state the facts especially that support that belief. IF THE SPACE PROVIDED IS INADEQUATE PLEASE ATTACH ADDITIONAL PAGES. Paragraph 2: In 2a, select the condition or conditions that you believe will result from the mental illness that the Respondent is currently exhibiting . You may select more than one if you have reason to believe that such allegations are true. NOTE: On Nov 17, 2009, the Illinois Appellate Court issued its decision in a case entitled In re Torski C. ___ Ill. A. 3d _____ (2009) (Docket4-08-952). That decision declared that the ground stated at Paragraph 2a iv was too vague to satisfy constitutional requirements. The decision can also be interpreted to have reached the same conclusion as to the grounds set out at Paragraph 2a ii. Some lawyers believe that this decision was erroneous. There may be an appeal to the Illinois Supreme Court. In the meantime, there is legal uncertainty as to the proper manner to proceed in these cases. Please understand that selection of only Paragraph 2a ii and/or 2a iv of these allegations may result in the summary dismissal of the Petition." Select Paragraph 2b only if the facts suggest that immediate hospitalization is necessary to protect the Respondent or another from physical harm. The Mental Health Code does allow for the involuntary admission of a Respondent to a mental health facility i.e., outpatient clinic or a treatment facility other than a hospital if the grounds in Paragraph 2a are present. No person may be detained in a hospital or mental health facility unless facts exist establishing that immediate hospitalization is necessary to prevent physical harm to the Respondent or another. The term immediate harm can include situations where the Respondent is unable to care for his or her basic needs without the intervention of family or friends. Paragraph 3: Select 3a or 3b depending on the Respondent's status. If he or she is not in a hospital or mental health facility select 3a. You must then state whether the Respondent has been examined by a qualified person who has certified that the Respondent is subject to involuntary admission. Please check Paragraphs 3a i., ii., or iii. Two certificates are required. If they have not been obtained, the judge will only initially determine whether an examination should be ordered. The Respondent is entitled to notice of such hearing unless an emergency exists. If you believe that such an emergency exists, check the box below 3a iii. Do not complete Paragraph 3b; if you have chosen 3a. Paragraph 3b should be selected when a patient has been detained in a hospital or mental health facility. Check 3b i. if the person has been detained on an emergency basis. Please provide all other information requested in that Section. If the facility has received a written request for discharge from a patient on voluntary status, select 3b ii. Check 3b iii, if the Respondent has failed to timely reaffirm their voluntary status at the facility. NOTE: Two (2) certificates must accompany the filing of the Petition if the individual was a voluntary patient. Paragraphs 4, 5, 6 and 7: Please provide all information requested. Attach a copy of any Power of Attorney that has been located. Paragraph 8: A Petitioner has the right prior to a hearing in this case to request admission to a mental health facility as an informal or voluntary recipient of services. If the Facility Director accepts the request for admission this Petition will normally be dismissed. As the Petitioner, you have a right to appear in court and object to the dismissal of the Petition. Check the box for Paragraph 8 if you want the Facility Director to give you notice of the acceptance of the Respondent as an informal or voluntary recipient. Upon receipt of such a notice, you must then contact the State's Attorney's Office Seniors and Persons with Disabilities Unit (312) 603-8600 to arrange for an appearance in Court. Wherefore Clause: Check box A in all cases. If the person has been detained on an emergency basis or you have submitted the required two certificates with the Petition involving a person who has not been detained; No other box should be checked. Check box B if the Respondent has not been examined by two mental health providers who executed "Certificates" in connection with this Petition. Check boxes C and D when facts suggest that immediate hospitalization is necessary to protect the Respondent or another from physical harm. Signature Clause: Please sign the Petition and provide all the requested information. Hospital Personnel: Please provide all the information requested when the Respondent is admitted as an inpatient. Make certain that you provide the Respondent with a copy of the entire 5 page Petition. The best practice would be to sign and date the Petition immediately after serving him or her with the Petition and advising him or her of the Rights of Admittee and Rights of Recipient Receiving Mental Health and Developmental Disability Services. Be certain to complete both signature pages. (1/14/10) CCCO 0079 MHDD 05 (Page 1 of 5) Petition for Involuntary Admission to a Mental Health Facility IN THE CIRCUIT COURT OF COOK COUNTY, ILLINOIS COUNTY DEPARTMENT, COUNTY DIVISION In the Matter of (1/14/10) CCCO 0079 MHDD 05 A _______________________________________________________ Responde