M.H.L. §943 General Form 13b (Order Directing Emergency Evaluation) 8/2010 At a term of the Family Court of the State of New York, held in and for the County of , at New York, on , . PRESENT: Hon. Judge .................................................................... In the Matter of a Proceeding under Article of the Family Court Act Docket No. ORDER DIRECTING EMERGENCY EVALUATION (Mental Hygiene Law §9.43) .................................................................... A petition under Article of the Family Court Act, sworn to on been filed in this court in the above-entitled proceeding alleging that And the matter having duly come on to be heard before this Court; and I. Required Determinations for Inpatient Examination [check applicable box(es)]: A.. This Court has jurisdiction over the petition and [specify person to be examined]: [Check applicable box]: is a person within the jurisdiction of this Court; is a parent or other person legally responsible for the care of a child who is within the jurisdiction of this Court; and B. [Specify person to be examined]: , a person before the court, has or may have a mental illness which is likely to result in serious harm to himself or herself or others based upon the following evidence presented [specify]: II. Required "Best Interests" and "Reasonable Efforts" Findings [Required in all cases in which the person to be remanded is a child who is the Respondent in a proceeding under Articles 3 or 7 of the Family Court Act or who is the subject of a proceeding under Article 10 of the Family Court Act or Social Services Law §§358-a, 384-b or 392; check applicable boxes and provide case-specific reasons in both A and B, below. If findings were previously made, so specify]: A. Continued placement in the Respondent's home [check applicable box]: Qwould Qwould not be contrary to the Respondent's best interests, based upon the following facts and for the following specific reasons [specify particular facts and reasons]: Specific documents or evidence supporting this finding include the following: Mental health evaluation, dated [specify]: Testimony of [specify]: Other [specify]: ; AND American LegalNet, Inc. www.FormsWorkFlow.com , , having Form GF-13b Page 2 B. Reasonable efforts, where appropriate, to prevent or eliminate the need for removal of the Respondent from the home, and , if the Respondent was removed prior to the date of the hearing, to return the Respondent safely to his or her home: were made as follows [specify reasonable efforts]: were not made but the lack of such efforts was appropriate based upon the following facts and for the following reasons [specify particular facts and reasons]: were not made. Specific documents or evidence supporting the finding in ¶B include the following: Mental health evaluation, dated [specify]: Testimony of [specify]: Other [specify]: NOW, therefore, it is ORDERED that [specify]: is remanded to [check applicable box]: The following hospital specified in section 9.39(a) of the Mental Hygiene Law [specify]: OR The following comprehensive psychiatric emergency program described in section 9.40(a) of the Mental Hygiene Law [specify]: for a determination by the director of such hospital or program whether such person should be retained therein pursuant to such section; and it is further ORDERED that the director of the hospital or program to which the remand is made shall, within ___ days after the completion of such examination, submit a report to this Court; and it is further ORDERED that this proceeding is adjourned to [specify date]: (ORDERED (and it is further) ). PURSUANT TO SECTION 1113 OF THE FAMILY COURT ACT, AN APPEAL FROM THIS ORDER MUST BE TAKEN WITHIN 30 DAYS OF RECEIPT OF THE ORDER BY APPELLANT IN COURT, 35 DAYS FROM THE DATE OF MAILING OF THE ORDER TO APPELLANT BY THE CLERK OF COURT, OR 30 DAYS AFTER SERVICE BY A PARTY OR THE ATTORNEY FOR THE CHILD UPON THE APPELLANT, WHICHEVER IS EARLIEST. ENTER ____________________________________ Judge of the Family Court Dated: , . Check applicable box: 9 Order mailed on [specify date(s) and to whom mailed ]:___________________________ 9 Order received in court on [specify date(s) and to whom given]:_____________________ American LegalNet, Inc. www.FormsWorkFlow.com