In the matter of First, middle, and last name 1. � The individual presently resides at � � own home or with relatives � � a facility � � a hospital � � a private facility � � en-US � and the address is en-US en-US . � 2. � The individual was placed on authorized leave on en-US en-US and continues on leave status. 3. � By order of this court dated en-US en-US the individual was placed in a � � a. � one-year assisted outpatient treatment program. � � b. � one-year combined treatment program. � � c. � one-year continuing hospitalization program. � � d. � facility as a judicial admission. 4. � I believe the individual has mental illness and � � a. � as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or � � � � � � � � � � � � � � � � � � � that are substantially supportive of this expectation. � b. � as a result of that mental illness, the individual is unable to attend to those basic physical needs 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. � c. � the individual222s judgment 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 a relapse or harmful deterioration of his or her condition, � � � � � � � � � � � � � � � � � 5. � I believe the individual has an intellectual disability and � a. � can be reasonably expected in the near future to intentionally or unintentionally seriously physically injure self or � another person and has overtly acted in a manner substantially supportive of that expectation. � � � � � � � � � � � � � � � � � � American LegalNet, Inc. www.FormsWorkFlow.com File No. 6. � This conclusion is based on � a. the following facts of which I have personal knowledge: � � en-US � en-US � b. the following facts, which are based on reports by others whose names and addresses, if known, are: � � en-US � en-US � 7. � The � � assisted outpatient treatment program � en-US en-US(For judicial admission)en-US outpatient program of care and treatment � provided to the individual since the order, and the results are: � en-US � en-US � en-US � en-US � en-US 8. � This treatment � � is � � is not � adequate and appropriate to the individual's condition. The estimated time required � for further treatment is � en-US � � days. � � � � � � � � � � � � during the next six-month period, or proposed as � � assisted outpatient treatment, � � en-US en-US(For judicial admission) en-USoutpatient program of care and treatment, � and will be adequate and appropriate to the individual's condition: � � � � � � � � � en-US � en-US � en-US � en-US � en-US 9. � The individual � � should be discharged from the treatment program. � � en-UScontinues to be a person requiring treatment. � � continues to be a person meeting the criteria for judicial admission for treatment. en-USI declare under the penalties of perjury that this report has been examined by me and that its contents are true to the best of en-USmy information, knowledge, and belief. en-USDate � en-USSignature of physician or licensed psychologist � en-USName (type or print) � en-USTitle � en-USTelephone no. American LegalNet, Inc. www.FormsWorkFlow.com