In the matter of First, middle, and last name 1. þ The individual presently resides at þ þ own home or with relatives þ þ a facility þ þ a hospital þ þ a private facility þ þ en-US þ and the address is en-US en-US . þ 2. þ The individual was placed on authorized leave on en-US en-US and continues on leave status. 3. þ By order of this court dated en-US en-US the individual was placed in a þ þ a. þ one-year assisted outpatient treatment program. þ þ b. þ one-year combined treatment program. þ þ c. þ one-year continuing hospitalization program. þ þ d. þ facility as a judicial admission. 4. þ I believe the individual has mental illness and þ þ a. þ as a result of that mental illness, the individual can reasonably be expected within the near future to intentionally or þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ that are substantially supportive of this expectation. þ b. þ as a result of that mental illness, the individual is unable to attend to those basic physical needs that must be attended þ to in order to avoid serious harm in the near future, and has demonstrated that inability by failing to attend to those basic þ physical needs. þ c. þ the individual222s judgment is so impaired by that mental illness and whose lack of understanding of the need for treatment þ has caused him or her to demonstrate an unwillingness to voluntarily participate in or adhere to treatment that is þ necessary, on the basis of competent clinical opinion, to prevent a relapse or harmful deterioration of his or her condition, þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ 5. þ I believe the individual has an intellectual disability and þ a. þ can be reasonably expected in the near future to intentionally or unintentionally seriously physically injure self or þ another person and has overtly acted in a manner substantially supportive of that expectation. þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ þ American LegalNet, Inc. www.FormsWorkFlow.com File No. 6. þ This conclusion is based on þ a. the following facts of which I have personal knowledge: þ þ en-US þ en-US þ b. the following facts, which are based on reports by others whose names and addresses, if known, are: þ þ en-US þ en-US þ 7. þ The þ þ assisted outpatient treatment program þ en-US en-US(For judicial admission)en-US outpatient program of care and treatment þ provided to the individual since the order, and the results are: þ en-US þ en-US þ en-US þ en-US þ en-US 8. þ This treatment þ þ is þ þ is not þ adequate and appropriate to the individual's condition. The estimated time required þ for further treatment is þ en-US þ þ days. þ þ þ þ þ þ þ þ þ þ þ þ during the next six-month period, or proposed as þ þ assisted outpatient treatment, þ þ en-US en-US(For judicial admission) en-USoutpatient program of care and treatment, þ and will be adequate and appropriate to the individual's condition: þ þ þ þ þ þ þ þ þ en-US þ en-US þ en-US þ en-US þ en-US 9. þ The individual þ þ should be discharged from the treatment program. þ þ en-UScontinues to be a person requiring treatment. þ þ 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 þ en-USSignature of physician or licensed psychologist þ en-USName (type or print) þ en-USTitle þ en-USTelephone no. American LegalNet, Inc. www.FormsWorkFlow.com