AOC-710 Rev. 1-14 Page 1 of 2 Doc. Code: PIH Case No. ____________________ Court County Division ____________________ District ____________________ ____________________ Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 202A.051 ; 202B.100 IN THE INTEREST OF: _____________________________________________ Respondent _____________________________________________ Residence _____________________________________________ Current Location _____________________________________________ Social Security Number / Date of Birth 1. ) ) ) ) ) ) ) ) ) ) ) ) ) ) Verified Petition for inVoluntary HosPitalization (Mental Illness) or inVoluntary admission (Intellectual Disability) PETITIONER, _______________________________________________________, states that he/she is: (Please print) q a reputable resident of __________________________ County, Kentucky, at _____________________ (Address) _____________________________________, _______________________, and is associated with the (Phone No.) Respondent as ________________________________, (Relationship) OR q a Qualified Mental Health Professional q a Qualified Professional in the area of intellectual disabilities located at ___________________________, Kentucky, and is associated with the Respondent as __________________, employed at __________________________________________________________, ____________________. (Hospital/Facility, etc.) (Phone No.) 2. PETITIONER states that the Respondent: or 504 (if 360 day proceeding) q has been hospitalized in a hospital or a forensic psychiatric facility for a period of 30 days within the preceding six (6) months under the provisions of KRS 202A q is a person with a mental illness q is a person with an intellectual disability, and that he/she presents a danger or threat of danger to self, family or others if not immediately restrained. 3. PETITIONER further states that the name, address, and residences of persons related to the Respondent are: (If unknown, so state) Parents or guardian: ___________________________________________________________________________ Spouse: _____________________________________________________________________________________ Person having custody: ________________________________________________________________________ Near relative: _________________________________________________________________________________ Other: _______________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com AOC-710 Rev. 1-14 Page 2 of 2 Doc. Code: PIH 4. PETITIONER believes that the Respondent is intellectual disability because: (state reasons) q a person with a mental illness q a person with an ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 5. PETITIONER states the following facts to indicate belief that Respondent is a danger or threat of danger to self, family or others because: (state reasons) ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ ____________________________________________________________________________________________ 6. Intellectual Disability proceedings only: Petitioner must attach to this Petition documentation establishing that the Respondent has an intellectual disability, INCLUDING the findings of a psychological examination or assessment completed in a reasonable time prior to the filing of this Petition that documents a Full Scale IQ in the moderate to severe range of an intellectual disability. KRS 202B.100(4)(f). PETITIONER requests that the Respondent be detained for examination, evaluation and hospitalization/admittance if he/she meets the criteria for: a) b) 7. q q involuntary hospitalization and that Respondent be hospitalized for q 60 Days or q 360 Days; or involuntary admission and that Respondent be admitted for an indeterminate period, to be reviewed within five (5) years of entry of this admission order. _____________________________________________ Signature of Petitioner __________________________________ Date ************ SUBSCRIBED AND SWORN TO before me this__________day of__________________________, ________. ___________________________________________________ Name/Title ___________________________________________________ County, Kentucky Attach copy of Petition to copy of each Warrant; Summons; or Order Appointing Counsel, Setting Preliminary Hearing and Appointing Physician/QMHP/QPID. American LegalNet, Inc. www.FormsWorkFlow.com