STATE OF NORTH CAROLINA County Name And Address Of Respondent File No. In The General Court Of Justice District Court Division IN THE MATTER OF: (PETITIONER IS CLINICIAN WHO HAS EXAMINED RESPONDENT) G.S. 122C-252, -261, -263, -281, -283 Social Security No. Of Respondent Date Of Birth Drivers License No. Of Respondent State FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT I. FINDINGS 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) 1. mentally ill and dangerous to self or others. In addition to being mentally ill, the respondent probably is also mentally retarded. (If this finding is made, see G.S. 122C261(b) and (d) for special instructions.) 2. a substance abuser and dangerous to self or others. TO ANY LAW ENFORCEMENT OFFICER: II. CUSTODY ORDER The Court ORDERS you to take the above named respondent into custody WITHIN 24 HOURS AFTER THIS ORDER IS SIGNED and transport the respondent directly to a 24-hour facility designated by the State for the custody and treatment of involuntary clients and present the respondent for custody, examination and treatment pending a district court hearing. Date Time AM PM Signature Deputy CSC Assistant CSC CSC Magistrate This Order is valid throughout the State. If the respondent is taken into custody, this Order is valid for seven (7) days from the date and time of issuance. III.RETURN OF SERVICE A. CUSTODY CERTIFICATION Respondent WAS NOT taken into custody for the following reason: I certify that this Order was received and the respondent served and taken into custody as follows: Date Respondent Taken Into Custody Name Of Law Enforcement Officer (Type Or Print) Name Of Law Enforcement Agency Time Signature Of Law Enforcement Officer Badge No. Of Officer AM PM NOTE TO LAW ENFORCEMENT OFFICER: If respondent is not taken into custody within 24 hours after this Order is signed, check the appropriate box above and return to the Clerk of Superior Court immediately. If respondent is served and taken into custody, complete return of service on the reverse. When taking respondent into custody you must inform him or her that he or she is not under arrest and has not committed a crime, but is being transported to receive treatment and for his or her own safety and that of others. Original-File Copy-24- Hour Facility Copy-Special Counsel Copy-Attorney General (Over) AOC-SP-302B, New 11/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com A 24-hour facility is not immediately available or medically appropriate. The respondent is being temporarily detained under appropriate supervision at the facility named below. Date Name Of Examining Facility Time B. FOR USE WHEN 24-HOUR FACILITY NOT IMMEDIATELY AVAILABLE OR MEDICALLY APPROPRIATE AM PM Name Of Examiner (Type Or Print) County Of Examining Facility Name Of Law Enforcement Officer (Type Or Print) Name Of Law Enforcement Agency Signature Of Law Enforcement Officer Badge No. Of Officer Respondent was temporarily detained under appropriate supervision at the site of first examination because the first examiner (petitioning clinician) recommended inpatient commitment and a 24-hour facility was not immediately available or medically appropriate. Upon further examination, an examiner determined that the respondent no longer meets the inpatient commitment criteria or meets the criteria for outpatient commitment. I returned the respondent to his/her regular residence or the home of a consenting person and released respondent from custody. Date Delivered Name Of Examining Facility Name Of Law Enforcement Officer (Type Or Print) Name Of Law Enforcement Agency Time Delivered C. FOR USE WHEN RESPONDENT RELEASED BEFORE TRANSPORT TO 24-HOUR FACILITY AM PM Name Of Examiner (Type Or Print) County Of Examining Facility Signature Of Law Enforcement Officer Badge No. Of Officer NOTE TO LAW ENFORCEMENT OFFICER: Upon completing this section, immediately return this form and the examiner's written report (Form No. DMH 5-72-01) to the Clerk of Superior Court of the county where the petition was filed and the custody order issued (See top of reverse side). D. PATIENT DELIVERY TO 24-HOUR FACILITY Time Delivered County Of 24-Hour Facility Signature Of Law Enforcement Officer I transported the respondent and placed him/her in the custody of the 24-hour facility named below. Date Delivered Name Of 24-Hour Facility Name Of Law Enforcement Officer (Type Or Print) Name Of Law Enforcement Agency AM PM Badge No. Of Officer NOTE TO LAW ENFORCEMENT OFFICER: Upon completing this section, immediately return this form to the Clerk of Superior Court of the county where the petition was filed and the custody order issued (See top of reverse side). AOC-SP-302B, Side Two, New 11/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com