COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . AOC-720. . . . . . .Doc..Code: OE or CEH : Rev. 10-02 Page 1 of 4 Index No. Case : Commonwealth of Kentucky www.kycourts.net Court of Justice KRS 202A.051, 202A.056, 202A.061; 202B : Plaintiff(s) -against- Calendar No. Court JUDICIAL SUBPOENA County District : : ) EXAMINATION ORDER AND EXAMINATION ) : CERTIFICATIONS FOR INVOLUNTARY ) HOSPITALIZATION (Chapter 202A) OR ) Defendant(s) __________________________________________________, INVOLUNTARY ADMISSION (Chapter 202B) : . . . . . . . . . . . . . Respondent . . . . . . . . . . . . . . . . . . . . ) . . . . . . . . . ........... . IN THE INTEREST OF: (Check the appropriate block) [ ] 60 Day Involuntary Hospitalization KRS Chapter 202A THE PEOPLE OF THE STATE OF NEW YORK TO GREETINGS: [ ] 360 Day Involuntary Hospitalization KRS Chapter 202A (If this is a 360 day proceeding, it has been certified to this Court that the patient has been hospitalized in a hospital or a forensic psychi atric facility for a period of 30 days within the preceding six months under provisions of KRS 202A or 504.) WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before , the Honorable at the ] Involuntary Admission Court [ located at County of KRS Chapter 202B in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as * witness*in this action on the part of the ** a*** ** ORDER Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a Kentucky Licensed Physician, and______________________________________________________________, a Kentucky result of your failure to comply. IT IS HEREBY ORDERED THAT_________________________________________________________________, M.D., a Licensed Physician, or [ ] other Qualified Mental Health Professional or [ ] other Qualified Mental Retardation , one of the Justices of the Professional, areWitness, Honorable the Respondent at__________________________________________(“Hospital” or appointed to examine other Court in and reportCounty, Facility), their findings to of day this Court within twenty-four (24) hours of the date of examination , 20 (excluding weekends and holidays), and that__________________________________________________________, an Attorney of this Court, is appointed to represent the Respondent. If the above-named Physician is an Authorized Staff Physician of a Hospital, he/she may admit the Respondent to that Hospital pending a Preliminaryabove and type name below) (Attorney must sign Hearing if he/she believes that the Respondent should be hospitalized, and further, that Respondent meets the criteria for involuntary hospitalization pursuant to provisions of KRS 202A or KRS 202B. In this case, the Authorized Staff Physician shall notify this Court of the Respondent's admission to said Hospital. The Hospital is authorized to further hold Respondent, who is presently being held under the provisions Attorney(s) for of 202A or 202B, for purposes of examination by the above-named Physician and/or other Qualified Mental Health/Retardation Professional pending the Preliminary Hearing until released by the above-named Physician or until further order of Court, whichever occurs first. Office and P.O. Address __________________________________________________ __________________________________________________ Date Judge Telephone No.: Please print or No.: name of Judge in the space Facsimile type provided below: E-Mail Address: Mobile Tel. No.: __________________________________________________ American LegalNet, Inc. www.USCourtForms.com COURT COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... Rev. 10-02 . . . . . . . : Page 2 of 4 CERTIFICATION Note: : Index No. Calendar No. The Certifications attached must be completed by two “Qualified Mental Health/Retardation Professionals.” At : JUDICIAL each professional is Plaintiff(s) least one certification must be completed by a physician or psychiatrist. Criteria forSUBPOENA listed below. -against: “Qualified mental health professional” under KRS 202A (mental illness) means: : a. A physician licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the performance of official duties. : b. A psychiatrist licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the government of the United States while engaged in the practice of official duties, who is certified or eligible to apply for certification by the American Board Defendant(s) and Neurology, Inc. of Psychiatry : . . . . . . . . . . . . . . . . . . . . service . . . . . . . . . . . . . . . . . . . c. . . A .psychologist .with. the. health . . . . . . provider. designation, .a. psychological practitioner, a certified psychologist, or a psychological associate, licensed under the provisions of KRS Chapter 319. d. A licensed registered nurse with a master’s degree in psychiatric nursing from an accredited institution and two (2) years of clinical experience with mentally ill persons; or a licensed registered nurse, with a bachelor’s degree in PEOPLE OF THE STATE OF NEW YORK THEnursing from an accredited institution, who is certified as a psychiatric and mental health nurse by the American Nurses Association and who has three (3) years of inpatient or outpatient clinical experience in psychiatric nursing and is currently employed by a hospital or forensic psychiatric facility licensed by the TO Commonwealth or a psychiatric unit of a general hospital or a private agency or company engaged in provision of mental health services or a regional community mental health and mental retardation program. e. A licensed clinical social worker licensed under provisions of KRS 335.100, or a certified social worker licensed under the provisions of KRS 335.080 with three (3) years of inpatient or outpatient clinical experience in psychiatric GREETINGS: social work and currently employed by a hospital or forensic psychiatric facility licensed by the Commonwealth or a psychiatric unit of a general hospital or a private agency or company engaged in the provision of mental health servicesWE a regional community that all business and excuses being laid aside, you and each of you attend before or COMMAND YOU, mental health and mental retardation program. f. the Honorableand family therapist licensed under the the A marriage at provisions of KRS 335.300 to 335.399 with three (3) years of , Court inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital located at County of or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency or in company engaged on the room , in providing day of health services, or a at , 20 , regional community the o'clock in mental health and mental recessed noon, and at any mental orretardation program.testify and give evidence as a witness in this action on the part of the adjourned date, to g. A professional counselor credentialed under the provisions of KRS Chapter 335.500 to 335.599 with three (3) years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency Your failure engaged inwith this subpoena is punishable as aa regional of court and will make you liable to or company to comply providing mental health services, or contempt community mental health and mental on whose program. the party retardation behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result of your failure to comply. “Qualified mental retardation professional” under KRS 202B (mental retardation) means: a. A physician licensed under the laws of Kentucky to practice medicine or osteopathy, or a medical officer of the Witness, Honorable , duties. government of the United States while engaged in the performance of official one of the Justices of the b. Court in A psychologist with County, service provider designation, a psychological practitioner, a certified psychologist, the health day of , 20 or a psychological associate licensed under the provisions of KRS Chapter 319. c. A licensed registered nurse with a master’s degree in psychiatric nursing from an accredited institution and two (2) years of clinical experience of which one (1) year is with mentally retarded persons; or a licensed registered nurse, with a bachelor’s degree in nursing from an accredited (Attorney must signhas three type name below) institution, who above and (3) years of inpatient or outpatient clinical experience of which one (1) year is in the field of mental retardation and is currently employed by a ICF/MR licensed by the cabinet, a hospital, a regional community mental health and mental retardation program, or a private agency or company engaged in the provision of mental retardation services. d. A licensed clinical social worker licensed under the provisions of KRS 335.100, or a certified social worker Attorney(s) for licensed under the provisions of KRS 335.080 with two (2) years of inpatient or outpatient clinical experience in social work of which one (1) year shall be in the field of mental retardation and is currently employed by an ICF/ MR licensed by the cabinet, a hospital, a regional community mental health and mental retardation program, or a private agency or company engaged in the provision of mental retardation services e. A marriage and family therapist licensed under the provisionsOffice and P.O. Address of KRS 335.300 to 335.399 with three (3) years of inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency or company engaged in providing mental health services, or a regional community mental health and mental Telephone No.: retardation program. f. A professional counselor credentialed under the provisions of Facsimile No.: 335.599 with three (3) years of KRS 335.500 to inpatient or outpatient clinical experience in psychiatric mental health practice and currently employed by a hospital E-Mail Address: or forensic facility licensed by the Commonwealth, a psychiatric unit of a general hospital, a private agency or Mobile Tel. No.: company engaged in providing mental health services, or a regional community mental health and mental retardation program. American LegalNet, Inc. www.USCourtForms.com : : Rev. 10-02 Page 3 of 4 Defendant(s) : ...................................................... Number 1 Certification AFFIANT states that he/she has examined the Respondent, ___________________________________________ THE PEOPLE OF THE STATE [ ] is YORK and in his/her opinion, Respondent OF NEWor [ ] is not: TO [ ] Mentally Ill or [ ] Mentally Retarded, and presents a danger or threat of danger to self, family or others; Respondent can reasonably benefit from this treatment; and hospitalization is the least restrictive alternative mode of treatment presently available. 1. GREETINGS: support your belief that the Respondent is a danger or threat of danger to self, family or others What facts if not hospitalized? WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________________________________________________________ , the Honorable at the Court located at County of _____________________________________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ What facts support your belief that hospitalization is the least restrictive alternative mode of treatment Your failure to presently available? comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result _____________________________________________________________________________________________ of your failure to comply. _____________________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in 3. County, day of , 20 _____________________________________________________________________________________________ Diagnostic Impression: a. b. 4. _______________________________________________________________________________________ (Attorney must sign above and type name below) _______________________________________________________________________________________ Attorney(s) for Date Examination Performed: _____________________________________________________________________________________________ Office and P.O. Address ___________________________________________ Date Telephone No.: Facsimile No.: _________________________________________________________ (Signature/Title) E-Mail Address: Mobile Tel. No.: * * * * * * * American LegalNet, Inc. www.USCourtForms.com SUBSCRIBED AND SWORN TO before me this __________ day of _________________________ , 2_________ . MY COMMISSION EXPIRES: _______________________________________________________ Notary Public _______________________________________________________ County, Kentucky : Rev. 10-02 Page 4 of 4 Defendant(s) : ...................................................... Number 2 Certification AFFIANT states that he/she has examined the Respondent, ___________________________________________ THE PEOPLE OF Respondent [ ] is YORK and in his/her opinion,THE STATE OF NEWor [ ] is not: TO [ ] Mentally Ill or [ ] Mentally Retarded, and presents a danger or threat of danger to self, family or others; Respondent can reasonably benefit from this treatment; and hospitalization is the least restrictive alternative mode of treatment presently available. 1. GREETINGS: support your belief that the Respondent is a danger or threat of danger to self, family or others What facts if not hospitalized? WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before _____________________________________________________________________________________________ , the Honorable at the Court located at County of _____________________________________________________________________________________________ in room , on the day of , 20 , at o'clock in the noon, and at any recessed or adjourned date, to testify and give evidence as a witness in this action on the part of the _____________________________________________________________________________________________ 2. _____________________________________________________________________________________________ What facts support your belief that hospitalization is the least restrictive alternative mode of treatment Your failure to presently available? comply with this subpoena is punishable as a contempt of court and will make you liable to the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a result_____________________________________________________________________________________________ of your failure to comply. _____________________________________________________________________________________________ Witness, Honorable , one of the Justices of the Court in 3. County, day of , 20 _____________________________________________________________________________________________ Diagnostic Impression: a. b. 4. _______________________________________________________________________________________ (Attorney must sign above and type name below) _______________________________________________________________________________________ Attorney(s) for Date Examination Performed: _____________________________________________________________________________________________ Office and P.O. Address Telephone No.: ___________________________________________ Date _________________________________________________________ Facsimile No.: (Signature/Title) E-Mail Address: Mobile Tel. No.: * * * * * * * American LegalNet, Inc. www.USCourtForms.com SUBSCRIBED AND SWORN TO before me this __________ day of _________________________ , 2_________ . MY COMMISSION EXPIRES: _______________________________________________________ Notary Public _______________________________________________________ County, Kentucky