AOC-700A Rev. 2-17 Page 1 of 3 Doc. Code: PIHAD COM M O NW E A LT H O F K E lex et justitia Case No. ____________________ Court County Division ____________________ District ____________________ ____________________ NT U C KY Commonwealth of Kentucky Court of Justice www.courts.ky.gov KRS 222.432 RT OF JUS TI Verified Petition for 60/360 day inVoluntary treatment (alcohol/drug abuse) IN THE INTEREST OF: _________________________________________________________________ Respondent's Name (please print) RESPONDENT'S RESIDENCE ADDRESS: (Please print) ______________________________________________________________________________________ ______________________________________________________________________________________ Phone Number: _________________________________ CURRENT LOCATION: (if different) ______________________________________________________________________________________ ______________________________________________________________________________________ Phone Number: _________________________________ 1. PETITIONER, ______________________________________________________________________ Petitioner's Name (please print) PETITIONER'S ADDRESS: (Please print) ___________________________________________________________________________________ ___________________________________________________________________________________ Phone Number: _________________________________ states that he/she is: q Spouse; q Relative; q Friend; or q Guardian, of the above-named Respondent. 2. PETITIONER further states that the name, address, and residence of persons related to the Respondent are: (if unknown, so state) Parents or guardian: _________________________________________________________________________________ Spouse: ___________________________________________________________________________________________ Person having custody of Respondent: ________________________________________________________________ Near relative: _______________________________________________________________________________________ Other: _____________________________________________________________________________________________ 3. PETITIONER believes that the Respondent is a person suffering from alcohol and/or other drug abuse because: (state facts to support belief) ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ ___________________________________________________________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com C CO U E AOC-700A Rev. 2-17 Page 2 of 3 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: q q involuntary treatment for not more than sixty (60) consecutive days; or involuntary treatment for not more than three hundred and sixty (360) consecutive days. ____________________________________________ Signature of Petitioner ________________________________, 2______ Date ____________________________________________ Name of Petitioner (please print) SUBSCRIBED AND SWORN TO before me this ________ day of ___________________________, ________. __________________________________________________ Name/Title __________________________________________________ County, Kentucky The Petitioner or other authorized person (spouse, relative, friend, or guardian) must guarantee all cost for treatment. Page 3, "Guarantee of Payment," must be completed and notarized. American LegalNet, Inc. www.FormsWorkFlow.com AOC-700A Rev. 2-17 Page 3 of 3 GUARANTEE OF PAYMENT Pursuant to KRS 222.432(4)(f), either the Petitioner or other authorized person (spouse, relative, friend, or guardian) shall guarantee any and all costs for treatment of the Respondent for alcohol and other drug abuse, as may be hereinafter ordered by the Court. The GUARANTEE below shall be completed by either the Petitioner or other authorized person. By my signature below, I do hereby assume responsibility for and 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. ___________________________________, 2_____ Date ____________________________________________ Name (please print) _____________________________________________ Relationship to Respondent (Petitioner, or Spouse, Relative, Friend, Guardian) ____________________________________________ Signature Billing Address: ____________________________________________ ____________________________________________ ____________________________________________ Subscribed and sworn to before me on this __________ day of _________________________________, 2________. My Commission expires: ____________________ ____________________________________________ Name/Title or Notary Public ____________________________________________ 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.FormsWorkFlow.com