In the matter of First, middle, and last name þ 1. þ I am the individual, and I demand a court hearing. þ 2. I am the þ þ hospital director/designee, þ þ outpatient treatment provider/designee, þ and I demand a court hearing þ þ because þ þ the individual refuses to accept prescribed treatment. þ þ the individual orally demanded a hearing. þ 3. þ I am the executive director of the community mental health services program. The individual deferred the initial hearing and þ is participating in an outpatient treatment program in the community. The deferral period ends on en-USDateen-US . þ þ þ I believe s/he continues to require treatment, but s/he refuses to sign a voluntary treatment form, and I demand a þ court hearing. þ þ I believe s/he continues to require treatment, but s/he is found not suitable for voluntary treatment, and I demand a þ court hearing. þ 4. þ I am the director of the hospital where the individual has remained hospitalized since deferring the initial hearing on þ en-USDateen-US . I believe the individual continues to require treatment and þ þ will not agree to sign a formal voluntary admission, and I demand a court hearing. þ þ is not suitable for voluntary admission, and I demand a court hearing. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ transport the individual to the en-US en-US hospital pending the hearing. 6. þ The individual is located at en-US þ en-US en-US . en-USDate þ en-USSignature þ en-USName (type or print) þ en-USAddress þ en-USCity, state, zipen-US(Complete only if item 5 is checked.) 1. þ Date of hearing: en-US þ Judge: þ þ Bar no. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ en-USSignatureen-USORDER American LegalNet, Inc. www.FormsWorkFlow.com