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