NHJB-2826-D (03/20/2019) Page 1 of 7 THE STATE OF NEW HAMPSHIRE JUDICIAL BRANCH http://www.courts.state.nh.us Court Name: Case Name: Case Number: (if known) PETITION AND CERTIFICATE FOR INVOLUNTARY EMERGENCY ADMISSION (IEA) Date: Name of person sought to be admitted INSTRUCTIONS TO PETITIONER: 1. Involuntary Emergency Admission (IEA) Forms: a. Petition: (pages 2 - 3) Any 223responsible person224 may be the petitioner. S/he should complete and sign the 223Petitioner222s Statement.224 The petitioner must be prepared to testify at the IEA hearing. Only one person may be the petitioner. The petitioner must include specific information about the person222s behaviors deemed to be dangerous as a result of mental illness. b. Witness statement: (page 4) A 2nd person may complete and sign the 223Witness222s Statement224 and add information about the person222s dangerous behaviors. This information is not required, but a witness who completes the form should be prepared to testify. c. Physical exam and mental health exam: A physician, APRN, or designee shall complete and sign the physical exam (page 5) and mental health exam (page 6). A physician222s assistant may complete and sign pages 5 and/or 6 only if a supervising physician/APRN co-signs. d. Certificate: Only a physician or APRN, authorized by a community mental health center or designated receiving facility, may complete and sign the certificate of examining physician (page 7) (please note: designees and physician222s assistants may not complete and sign page 7.) e. Complaint and Prayer: If a person who is exhibiting dangerous behaviors towards self or others as a result of serious mental health symptoms will not consent to be taken to a hospital emergency room, a responsible person may complete and sign a petition (pages 2-3) and a complaint and prayer. The petitioner shall give the complaint and prayer, after it has been also signed by a justice of the peace, with the IEA petition (pages 2-3 completed), to a law enforcement officer who is authorized to locate the person and deliver her/him to a local hospital for an emergency mental health examination. If the person is willing to go to a hospital for a mental health evaluation, and it can be done safely, the complaint and prayer form is not needed. 2. Custody: After all 7 pages of the IEA form have been completed and signed, a law enforcement officer shall take the patient to the facility named in the physician222s certificate (page 7). (A doctor may order an ambulance for children. RSA 135-C:29(II)). 3. Hearing: The petitioner must attend an IEA hearing, which will be held by the Circuit Court within 3 days (excluding Sundays and holidays) after admission to a designated receiving facility. 4. Contact: All petitioners shall contact the Designated Receiving Facility (named on page 7 - where the person was involuntarily admitted on an emergency basis) during business hours to find out the date, place, and time of the hearing. If the petitioner does not attend the hearing, in person (or by phone at NHH), the petition may be dismissed and the person may be discharged back to the community. Designated Receiving facilities are: Cypress Center .................................. (603) 668-4111 ext.4175 Elliot Hospital .................................... (603) 663-4400 Franklin Hospital ............................... (603) 934-2060 New Hampshire Hospital .................. (603) 271-5751 or 271-5750 Portsmouth Regional Hospital ......... (603) 433-5270 NOTE: If you wish to testify by telephone, you must provide the Designated Receiving Facility with a direct phone number (not a receptionist) and be available when the Court Hearing Officer/Judge calls. You may be asked to testify to facts in addition to what you have written on the petition. You should have a copy of the petition with you so you can refer to it during the hearing. American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION AND CERTIFICATE FOR INVOLUNTARY EMERGENCY ADMISSION (IEA) NHJB-2826-D (03/20/2019) Page 2 of 7 PETITIONER222S STATEMENT To the Honorable Judge/ Hearing Officer of the : Court Name 1. I respectfully represent that Name of petitioner Name of person sought to be admitted DOB Age of # and Street (Do not list PO Box) City State Zip needs to be involuntarily admitted, to a Designated Receiving Facility, on an emergency basis, because s/he is in such a mental condition as a result of mental illness as to pose a likelihood of danger to self or others. I understand that a Designated Receiving Facility is a hospital, in New Hampshire, specifically authorized to treat a person222s acute symptoms of mental illness. 2. I believe s/he has engaged in the following dangerous acts: (check one or more boxes) RSA 135-C:27(I) (Danger to self) (a). Within the past forty (40) days, s/he has inflicted serious bodily injury on him/herself or has attempted suicide or serious self-injury and there is a likelihood the act or attempted act will recur if admission is not ordered. RSA 135 - C:27, 1(a). (b). Within the past forty (40) days, s/he has threatened to inflict serious bodily injury on him/herself and there is a likelihood that an act or attempt of serious self-injury will occur if admission is not ordered. RSA 135-C:27 1(b). (c). The person222s behavior demonstrates that s/he so lacks the capacity to care for his/her own welfare that there is a likelihood of death, serious bodily injury, or serious debilitation if admission is not ordered. RSA 135-C:27 1(c). (d). The person meets all of the following criteria: The person has been determined to be severely mentally disabled in accordance with rules authorized by RSA 135-C:61 for a period of at least one year; (1) The person has had at least one probate court involuntary admission, within the last two years, pursuant to RSA 135-C:34-54; (2) The person has no guardian of the person appointed pursuant to RSA 464-A; (3) The person is not subject to a conditional discharge granted pursuant to RSA 135-C:49,II; (4) The person has refused the treatment determined necessary by a mental health program approved by the Department of Health and Human Services; and (5) A psychiatrist or APRN as defined in RSA 135-C:2, II-a, at a mental health program approved by the Department of Health and Human Services has determined, based upon the person222s clinical history, that there is a substantial probability that the person222s refusal to accept necessary treatment will lead to death, serious bodily injury, or serious debilitation if Involuntary Emergency Admission is not ordered. RSA 135-C:27(II) (Danger to others) Within the past forty (40) days s/he inflicted, attempted to inflict, or threatened to inflict serious bodily harm on another. American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION AND CERTIFICATE FOR INVOLUNTARY EMERGENCY ADMISSION (IEA) NHJB-2826-D (03/20/2019) Page 3 of 7 PETITIONER222S STATEMENT (cont.) 1. Petitioner222s name: Relationship: Typed or printed name Address: # and Street (Do not list PO Box) City State Zip Telephone No.: Agency (if any): Describe all specific dangerous acts or behaviors that (Name of person sought to be admitted) engaged in. Limit your descriptions to acts or behaviors that happened within the last 40 days: Dangerous acts or behaviors may include: serious bodily injury to self, attempted suicide; threats to harm self or to commit suicide; lack of capacity to provide adequate food, clothing, shelter; and/or maintain a safe personal environment; threats to inflict, or actions that inflicted, or were intended to inflict serious bodily harm on another. Note: Did you personally observe the acts or behaviors? If not, explain how you know about the acts or behaviors and list the name (and phone # if you have it) of the person who observed the acts or behaviors. (Attach additional pages as necessary.) Date: Time: Place: Description: Date: Time: Place: Description: REQUIRED SIGNATURE: Date Signature of petitioner Print or type name of petitioner American LegalNet, Inc. www.FormsWorkFlow.com Case Name: Case Number: PETITION AND CERTIFICATE FOR INVOLUNTARY EMERGENCY ADMIS