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