File No. STATE OF NORTH CAROLINA COURT COUNTY .OF . . . . . . . . . .County. . . . . . . . . . . . . . . . . . . . . . . . . . ......... .. ...... : IN THE MATTER OF: In The General Court Of Justice District Court Division Index No. Name And Address Of Respondent : Calendar No. FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT : JUDICIAL SUBPOENA Plaintiff(s) -against- Of Birth Date Social Security No. Of Respondent G.S. 122C-261, -263, -281, -283 : Drivers License No. Of Respondent I. FINDINGS State : The Court finds from the petition in the above matter that there are reasonable grounds to believe that the facts alleged in the petition are : true and that the respondent is probably: (Check all that apply) Defendant(s) : . . . . . . . . . . . . . . . . . . . . . . . . . mentally . and . need of . . 1. .mentally ill .and.dangerous. to .self .or .others .or . . . . . . . ill . . . .in . . . . . . treatment in order to prevent further disability or deterioration that would predictably result in dangerousness. In addition to being mentally ill, the respondent probably is also mentally retarded. 2. a substance abuser and dangerous to self or others. THE PEOPLE OF THE STATE OF NEW YORK CUSTODY ORDER TO ANY LAW ENFORCEMENT OFFICER: TO The Court ORDERS you to take the above named respondent into custody 1. and take the respondent for examination by a person authorized by law to conduct the examination. (A COPY OF THE EXAMINER'S FINDINGS SHALL BE TRANSMITTED TO THE CLERK OF SUPERIOR COURT IMMEDIATELY.) GREETINGS: finds that the respondent IS NOT a proper subject for involuntary commitment, then you shall take the respondent IF the examiner home or to a consenting person's home in the originating county and release him/her. WE finds that the YOU, that all business and proper subject laid aside, commitment, of you shall take the IF the examinerCOMMANDrespondent IS mentally ill and a excuses beingfor outpatientyou and eachthen youattend before respondent home , the Honorable or to a consenting person's home in the originating county and release him/her. at the Court IF the examiner finds that the respondent IS mentally ill and a proper subject for inpatient commitment, then you shall transport the located at County of respondent in room to the 24-hour facility named of , on the day below for temporary custody, examination andin the , 20 , at o'clock treatment pending and at any recessed noon, a district court hearing. IF the examiner finds that the respondent IS a substance abuser and subject to involuntary commitment, the examiner must or adjourned date, to testify and give evidence as a witness in this action on the part of the recommend whether the respondent be taken to a 24-hour facility or released, and then you shall either release him/her or transport the respondent to the 24-hour facility named below for temporary custody, examination and treatment pending a district court hearing. 2. and transport the respondent directlywith this subpoena is punishable as a contempt of court and will make you liable to Your failure to comply to the 24-hour facility named below, for temporary custody, examination and treatment pending a district court hearing. (FOR PHYSICIAN/PSYCHOLOGIST PETITIONERS of $50 the party on whose behalf this subpoena was issued for a maximum penalty ONLY.) and all damages sustained as a result of your failure Name Of 24-Hour Facility For Mentally Illto comply. Date Time Or following facility designated by area authority: Witness, Honorable Court in County, Name Of 24-Hour Facility For Substance Abuser day of Or following facility designated by area authority: , one of the Justices of the , 20 AM PM Signature Assistant CSC Clerk Of Superior Court Deputy CSC (Attorney must sign above and type name below) Magistrate NOTE TO MAGISTRATE OR CLERK: If the respondent is mentally retarded in addition to being mentally ill, you must contact the area authority before issuing a custody order to determine the facility to which the respondent will be taken. If the area mental health authority where Attorney(s) for the respondent resides has a single portal plan, you must call the area authority to determine the appropriate 24-hour facility or other treatment before issuing any custody order. NOTE TO ANY LAW ENFORCEMENT OFFICER: You shall take the respondent into custody within 24 hours after the date this Order is signed. Without unnecessary delay after assuming custody, you shall take the respondent to an area facility for examination by a person authorized by law to conduct the examination; if an authorized examiner is not Office and P.O. Address immediately available in the area facility, you shall take the respondent to any authorized examiner locally available. If an authorized examiner is not available, you may temporarily detain the respondent in an area facility if one is available; if an area facility is not available, you may detain the respondent under appropriate supervision, in the respondent's home, in a private hospital or clinic, or in a general hospital, but not in a jail or other penal facility. Complete the Return Of Service on the reverse and return to the Clerk of Superior Court immediately. Telephone No.: Facsimile No.: E-Mail Address: Original-File Copy-Hospital Copy-Special Counsel Copy-Attorney General (Over) Mobile Tel. No.: AOC-SP-302, Rev. 9/03 2003 Administrative Office of the Courts American LegalNet, Inc. www.USCourtForms.com II. RETURN OF SERVICE Respondent WAS NOT taken into custody for the following reason: COURT COUNTY .OF . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .... .... . I certify .that this .Order was received and served as follows: : Date Respondent Taken Into Custody Time Index No. AM PM : Calendar No. A. FOR USE AFTER PRELIMINARY EXAMINATION : as shown below. 1. The respondent was presented to an authorized examiner locally availableJUDICIAL SUBPOENA Plaintiff(s) 2. The respondent was temporarily detained at the facility named below until the respondent could be examined by an -against: authorized examiner locally available. Date Presented Time Name Of Examiner AM : PM Name Of Local Facility : 1. Upon examination, the examiner named above found that the respondent is mentally ill and meets the criteria for Defendant(s) : . . . . . . . . commitment, . . . . . . . . . . . . . . . . . . and . . . . . . . . . . . outpatient . . . . . . . . . . . or is. a .substance abuser . . . .meets the criteria for commitment and the examiner recommends release pending a hearing. I returned the respondent to his/her regular residence or the home of a consenting person. 2. Upon PEOPLE OF the examiner named above found that the respondent is mentally ill and meets the criteria for THE examination, THE STATE OF NEW YORK inpatient commitment, or is a substance abuser and meets the criteria for commitment and the examiner recommends that the respondent be held pending the district court hearing. TO I transported the respondent and placed the respondent in the temporary custody of the facility named below for observation and treatment. I placed the respondent in the custody of the agency named below for transportation to the 24-hour facility. GREETINGS: 3. Upon examination, the examiner named above found that the respondent did not meet the criteria for inpatient or outpatient WE COMMAND YOU, the respondent to his/her regular residence or the home of a of you attend before commitment. I returned that all business and excuses being laid aside, you and each consenting person. , the Honorable at the Court located at County of The examiner's written statement is attached. will be forwarded. in room , on the day of , 20 , at o'clock in the noon, and at any recessed Name Of 24-Hour Facility Date Delivered Time Delivered Date Of Return or adjourned date, to testify and give evidence as a witness in this action on the part of the AM PM Name Of Transporting Agency Signature Of Law Enforcement Official Your failure toFOR USE WHEN PETITIONER IS PHYSICIAN/PSYCHOLOGIST will make you liable to B. comply with this subpoena is punishable as a contempt of court and the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a I transported the failure to comply. to and placed him/her in the temporary custody of the facility named below. result of your respondent directly Name Of 24-Hour Facility Date Delivered Witness, Honorable Court in County, Name Of Transporting Agency Time Delivered AM Date Of Return PM , one of the Justices of the day of Signature Of Law Enforcement Official , 20 C. FOR USE WHEN ANOTHER AGENCY TRANSPORTS THE RESPONDENT I took custody of the respondent from the officer named above, transported the respondent and placed him/her in the temporary custody of the facility named below for observation and (Attorney must sign above and type name below) treatment. Name Of 24-Hour Facility Date Delivered Time Delivered Name Of Transporting Agency Signature Of Law Enforcement Official Attorney(s) for AM Date Of Return PM D. FOR USE WHEN STATE FACILITY TRANSFERS WITHOUT ADMISSION Pursuant to G.S. 122C-261(f), I took custody of the respondent from the state 24-hour facility named above, where he/she was not admitted, and transported the respondent and placed him/her P.O. Address Office and in the temporary custody of the facility named below for observation and treatment. Name Of Facility To Which Transferred Date Delivered Time Delivered Name Of Transporting Agency Telephone No.: PM Signature Of Law Enforcement Or State Facility Official Facsimile No.: AM Date Of Return E-Mail Address: Mobile Tel. No.: AOC-SP-302, Side Two, Rev. 9/03, 2003 Administrative Office of the Courts American LegalNet, Inc. www.USCourtForms.com