en-USIn the matter of en-USFirst, middle, and last nameen-USOn en-USDateen-US , I examined the individual and report that: 1. � The individual � does � does not � meet the criteria for treatment. 2. � My diagnosis is that the individual � does � does not � have an intellectual disability. 3. � The individual � a. � can � cannot � be reasonably expected within the near future to intentionally or unintentionally � seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. � en-US b. has been arrested and charged with an offense that was a result of the intellectual disability. � I base my conclusion on the following facts: en-US � en-US � 4. � The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending � hearing. en-USDate � en-USSignature � en-USName and titleen-USOn en-USDateen-US , I examined the individual and report that: 1. � The individual � does � does not � meet the criteria for treatment. 2. � My diagnosis is that the individual � does � does not � have an intellectual disability. 3. � The individual � a. � can � cannot � be reasonably expected within the near future to intentionally or unintentionally � seriously physically injure self or others and has overtly acted in a manner substantially supportive of that expectation. � en-US b. has been arrested and charged with an offense that was a result of the intellectual disability. � I base my conclusion on the following facts: en-US � en-US � 4. � The individual requires immediate admission to a facility in order to prevent physical harm to self and others pending � hearing. en-USDate � en-USSignature � en-USName and titleen-USCERTIFICATION OF EXAMINERS American LegalNet, Inc. www.FormsWorkFlow.com File No. 1. � I, en-USNameen-US , as en-USProfession, organization, and titleen-US , � have met with and evaluated the individual and report that his/her mental, physical, social, and educational condition is: � en-US � en-US � en-US 2. � The following is a list of available forms of care and treatment that may serve as an alternative to admission to a facility. � a. � Residential placement: en-US � Availability (specify): en-US � b. � Day activity programs: en-US � en-US � Availability (specify): en-US � c. � Outpatient treatment: en-US � en-US � Availability (specify): en-US � d. � Custody of friend or relative: en-US � Availability (specify): en-US � e. � Home care or homemaker services: en-US � Availability (specify): en-US � f. � Inpatient treatment at private psychiatric hospital: en-US Name of hospital � Availability (specify): en-US � g. � Other: en-US � Availability (specify): en-US 3. � I recommend the most appropriate living arrangement for the individual in terms of type and location and the availability of � support services to be en-US en-US .en-USI declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best ofen-USmy information, knowledge, and belief. en-USDate � en-USAddress en-USSignature � en-USCity, state, zip Telephone no.en-USREPORT ON PETITION FOR JUDICIAL ADMISSION American LegalNet, Inc. www.FormsWorkFlow.com