AOC-700A Doc. Code: PIHAD Rev. 7-04 Page 1 of 2 Commonwealth of Kentucky Court of Justice www.kycourts.net KRS 222 Case No. _____________________ District Court ________________________ VERIFIED PETITION FOR INVOLUNTARY TREATMENT (ALCOHOL/DRUG ABUSE) County _______________________ IN THE INTEREST OF: RESPONDENT _________________________________________________________________________________________ RESPONDENT'S RESIDENCE ADDRESS ___________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Current Location (if different) 1. PETITIONER, __________________________________________________________________________ (Petitioner's Name-Please print) __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ (Petitioner's Address-Please print) states that he/she is: [ ] Spouse; 2. [ ] Relative; [ ] Friend; or [ ] Guardian, of the above-named Respondent. PETITIONER further states that the name, address, and residence of persons related to the Respondent are: (if unknown, so state) Parents or guardian:______________________________________________________________________ Spouse:_______________________________________________________________________________ Near relative:___________________________________________________________________________ Other:________________________________________________________________________________ 3. PETITIONER believes that the Respondent is a person suffering from alcohol and other drug abuse because: (state facts to support belief) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ American LegalNet, Inc. www.USCourtForms.com AOC-700A Doc. Code: PIHAD Rev. 7-04 Page 2 of 2 4. PETITIONER also believes that the Respondent presents a danger or threat of danger to self, family or others because: (state facts to support belief) ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ ______________________________________________________________________________________ 5. PETITIONER requests that the Respondent be detained for examination, evaluation and hospitalization/ admittance to a treatment facility if he/she meets the criteria for: [ [ 6. ] ] involuntary treatment for not more than sixty (60) consecutive days; or involuntary treatment for not more than three hundred and sixty (360) consecutive days. By signing this Verified Petition, the Petitioner does hereby assume responsibility for and does GUARANTEE PAYMENT FOR ALL COSTS incurred on behalf of the Respondent for all alcohol and other drug abuse treatment, including but not limited to, initial examination and transportation costs, as hereinafter ordered by the Court. The BILLING ADDRESS is the Petitioner's address as contained in this Verified Petition. __________________________________ Date _________________________________________ Signature of Petitioner _________________________________________ Name of Petitioner (please print) SUBSCRIBED AND SWORN TO before me this ____ day of ____________________, 2 ______. _________________________________________ Name/Title _________________________________________ County, Kentucky Attach copy of Verified Petition to each copy of Warrant, Summons, and Hearing, Examination and Appointment of Counsel Notice and Order. Distribution: Respondent; Petitioner; Respondent's Legal Guardian, Spouse, Parent(s), Near Relative or Friend (if applicable). American LegalNet, Inc. www.USCourtForms.com