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Affidavit And Petition For Involuntary Commitment Form. This is a North Carolina form and can be use in Special Proceedings Statewide.
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Tags: Affidavit And Petition For Involuntary Commitment, SP-300, North Carolina Statewide, Special Proceedings
File No.
STATE OF NORTH CAROLINA
In The General Court Of Justice
District Court Division
County
IN THE MATTER OF:
Name And Address Of Respondent
AFFIDAVIT AND PETITION FOR
INVOLUNTARY COMMITMENT
G.S. 122C-261, 122C-281
Date Of Birth
Drivers License No. Of Respondent
State
I, the undersigned affiant, being first duly sworn, and having sufficient knowledge to believe that the respondent is a proper
subject for involuntary commitment, allege that the respondent is a resident of, or can be found in the above named county,
and is:
(Check all that apply)
1. mentally ill and dangerous to self or others or mentally ill and in need of treatment in order to prevent further disability
or deterioration that would predictably result in dangerousness.
in addition to being mentally ill, respondent is also mentally retarded.
2. a substance abuser and dangerous to self or others.
The facts upon which this opinion is based are as follows: (State facts, not conclusions, to support ALL blocks checked.)
Name And Address Of Nearest Relative Or Guardian
Name And Address Of Person Other Than Petitioner Who May Testify
Home Telephone No.
Home Telephone No.
Business Telephone No.
Business Telephone No.
Petitioner requests the court to issue an order to a law enforcement officer to take the respondent into custody for
examination by a person authorized by law to conduct the examination for the purpose of determining if the respondent
should be involuntarily committed.
SWORN/AFFIRM AND SUBSCRIBED TO BEFORE ME
Date
Name And Address Of Petitioner (Type Or Print)
Signature
Deputy CSC
Assistant CSC
Notary (use only with physician
or psychologist petitioner)
SEAL
Signature Of Petitioner
Clerk Of Superior Court
Magistrate
Date Notary Commission Expires
Relationship To Respondent
County Where Notarized
Home Telephone No.
AOC-SP-300, Rev. 7/11
© 2011 Administrative Office of the Courts
Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General
(Over)
Business Telephone No.
PETITIONER'S WAIVER OF NOTICE OF HEARING
I voluntarily waive my right to notice of all hearings and rehearings in which the Court may commit the respondent or
extend the respondent's commitment period, or discharge the respondent from the treatment facility.
Signature Of Witness
Date
Signature Of Petitioner
NOTE: “Upon the request of the legally responsible person or the minor admitted or committed, and after that minor has both been released and
reached adulthood, the court records of that minor made in proceedings pursuant to Article 5 of [Chapter 122C] may be expunged from the files of the
court.” G.S. 122C-54(e)
AOC-SP-300, Side Two, Rev. 7/11
© 2011 Administrative Office of the Courts