In the matter of First, middle, and last name þ en-USPLEASE PRINT OR TYPE CLEARLY 1. þ I state that I have met with my legal counsel, a representative from the county community mental health program, and a þ member of the treatment team assigned to provide treatment. I agree to one of the following: þ þ a. þ Inpatient hospital treatment not to exceed 60 days. þ þ b. þ Outpatient treatment not to exceed 180 days. þ þ c. þ Combined hospitalization and outpatient treatment up to 180 days with hospitalization not to exceed 60 days. 2. þ The treatment program will be as follows: þ Hospitalization: en-US þ Outpatient treatment under the supervision of: en-US þ en-US þ en-US þ en-US þ en-US þ en-US þ þ en-US þ þ en-US þ en-US 3. þ I request that the court hearing be deferred for not longer than 60 days from today if I have chosen to remain hospitalized, or þ 180 days from today if I have chosen outpatient treatment or a combination of hospitalization and outpatient treatment. 4. þ I understand that I may refuse this treatment at any time during this deferral period and demand a court hearing. en-USDate þ en-USPatient222s signature þ Witness/Legal counsel þ Bar no. American LegalNet, Inc. www.FormsWorkFlow.com