STATE OF NORTH CAROLINA County Name And Address Of Respondent File No. IN THE MATTER OF: In The General Court Of Justice District Court Division FINDINGS AND CUSTODY ORDER INVOLUNTARY COMMITMENT (PETITIONER APPEARS BEFORE MAGISTRATE OR CLERK) State Date Of Birth Drivers License No. Of Respondent Social Security No. Of Respondent G.S. 122C-252, -261, -263, -281, -283 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 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, 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: The Court ORDERS you to take the above named respondent into custody WITHIN 24 HOURS AFTER THIS ORDER IS SIGNED 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.) IF the examiner finds that the respondent IS NOT a proper subject for involuntary commitment, then you shall take the respondent home or to a consenting person's home in the originating county and release him/her. IF the examiner finds that the respondent IS mentally ill and a proper subject for outpatient commitment, then you shall take the respondent home or to a consenting person's home in the originating county and release him/her. IF the examiner finds that the respondent IS mentally ill and a proper subject for inpatient commitment, then you shall transport the respondent 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. IF the examiner finds that the respondent IS a substance abuser and subject to involuntary commitment, the examiner must 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 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 II. CUSTODY ORDER 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 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-302A, New 11/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com B. PATIENT DELIVERY TO FIRST EXAMINATION SITE The respondent was presented to an authorized examiner as shown below: Date Presented Name Of Examining Facility Name Of Law Enforcement Officer (Type Or Print) Name Of Law Enforcement Agency Time AM PM Name Of Examiner (Type Or Print) County Of Examining Facility Signature Of Law Enforcement Officer Badge No. Of Officer C. FOR USE WHEN TRANSPORTING AFTER FIRST EXAMINATION: PATIENT RELEASED OR DELIVERED TO 24-HOUR FACILITY 1. The examiner found that the respondent does not meet the commitment criteria, or meets the criteria for outpatient commitment, or meets the criteria for substance abuse commitment and should be released pending a hearing. I returned respondent to his/her regular residence or the home of a consenting person and released respondent from custody. 2. The examiner found that the respondent is mentally ill and meets the criteria for inpatient commitment, or meets the criteria for substance abuse commitment and should be held pending a district court hearing. I transported and placed the respondent in the custody of the 24-hour facilty named below for observation and treatment. Name Of 24-Hour Facility County Of 24-Hour Facility 3. Respondent was temporarily detained under appropriate supervision at the site of first examination because the f irst examiner 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 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 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 a copy of 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). AOC-SP-302A, Side Two, New 11/12 © 2012 Administrative Office of the Courts American LegalNet, Inc. www.FormsWorkFlow.com