File No. STATE OF NORTH CAROLINA In The General Court Of Justice Superior Court Division Before the Clerk County IN THE MATTER OF: Name Of Respondent REQUEST AND ORDER FOR MULTIDISCIPLINARY EVALUATION Social Security No. Of Respondent (Last Four Digits Only) G.S. 35A-1111(a), (b) Name And Address Of Petitioner In Incompetency Proceeding Name And Address Of Counsel Or GAL For Respondent REQUEST I, the undersigned, request that the Court order a multidisciplinary evaluation be performed on the respondent named above. Name And Address Of Party Requesting Evaluation Date Signature FINDINGS The Court finds in accordance with the above request OR on its own motion that a multidisciplinary evaluation should should not be performed on the respondent. ORDER Based on these findings the request for multidisciplinary evaluation is denied. it is ORDERED that the following agency shall prepare and provide a current multidisciplinary evaluation of the respondent. The agency shall file the evaluation with the Clerk, and send copies to the petitioner and the counsel or guardian ad litem for the respondent not later than thirty (30) days after receipt of this order. Date Name And Address Of Designated Agency Signature Assistant CSC AOC-SP-901M, Rev. 7/06 © 2006 Administrative Office of the Courts Original-File Clerk of Superior Court Copy-Agency American LegalNet, Inc. www.FormsWorkflow.com