In the matter of First, middle, and last name � en-USTO THE EXAMINER: The following is a statement that must be read to the individual before proceeding with any questions.en-USI am authorized by law to examine you for the purpose of advising the court if you have a mental condition en-USwhich needs treatment and whether such treatment should take place in a hospital or in some other place. en-USI am also here to determine if you should be hospitalized or remain hospitalized before a court hearing is en-USheld. I may be required to tell the court what I observe and what you tell me. � 1. � I am a � � psychiatrist. � � licensed psychologist. � � physician. 2. � I certify that on this date I read the above statement to the individual before asking any questions or conducting any examination. 3. � I further certify that I, en-USName (type or print)en-US , personally examined en-USPatient � at en-USName and address where examination took place � on � en-USDateen-US starting at en-USTimeen-US and continuing for en-US en-US minutes. en-US en-USen-USwith other information which underlie your conclusion. en-USIndicate the source of any information not personally known or en-USobserved.en-USen-USperson requiring treatment or in need of hospitalization. 4. � My determination is that the person is � � � reality, or ability to cope with the ordinary demands of life). � � not mentally ill. � 5. � (if applicable) The person has � � convulsive disorder. � � alcoholism. � � other drug dependence. � � � mental processes weakened by reason of advanced years. � � other (specify): en-US 6. � My diagnosis is: en-US 7. � Facts serving as the basis for my determination are: en-US � en-US � en-US � � en-US American LegalNet, Inc. www.FormsWorkFlow.com File No. 8. � Explain in the space below the facts which lead you to believe that future conduct may result in en-US(check applicable box) � � � � Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near � � � � � Therefore, I believe that the examined person, as a result of mental illness, can reasonably be expected within the near � � � c. � inability to attend to basic physical needs. Facts: � Therefore, I believe that the examined person, as a result of mental illness, is unable to attend to those basic physical � needs (such as food, clothing or shelter) that must be attended to in order to avoid serious harm in the near future � and has demonstrated that inability by failing to attend to those basic physical needs. � � d. � inability to understand need for treatment. Facts: � Therefore, I believe that the examined person, as a result of mental illness, is so impaired by that mental illness and � whose lack of understanding of the need for treatment has caused him or her to demonstrate an unwillingness to � voluntarily participate in or adhere to treatment that is necessary, on the basis of competent clinical opinion, to prevent � � mental harm to himself/herself or others. 9. � I conclude the individual � � is � � is not � a person requiring treatment. 10. � (optional) I recommend � � hospitalization � � assisted outpatient treatment � as follows: en-US � en-US en-US .en-USI certify that I am a person authorized by law to certify as to the individual's mental condition. I am not related by blood or en-USen-USen-USme and that its contents are true to the best of my information, knowledge, and belief. en-USDate � en-USTime of signing � en-USSignature � en-USPrint or type name and business telephone no. American LegalNet, Inc. www.FormsWorkFlow.com