REQUEST FOR HEARING STATE OF NORTH CAROLINA Department of Health and Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse Services House Bill 95 Yes No If “Yes”, Clerk of Court notified by phone on Date: ____________ File #__________ Film #__________ Facility Name: _______________________________________________________________________________ Facility Address: _____________________________________________________________________________ COUNTY IN THE MATTER OF: Respondent’s name: _________________________________________________ Client Record Number: _____________ Unit/ Building/ Ward (when applicable): ___________________________________________________________________ TO: Clerk of Superior Court of _____________________ County This serves as official notice that an ❏ initial hearing, supplemental hearing, first rehearing, or subsequent rehearing needs to be scheduled for the above named respondent for the following reason: Inpatient Outpatient Combination Inpatient-Outpatient Substance Abuse treatment will be necessary beyond ________________________(Commitment Expiration Date) Attached is the Examination and Recommendation to Determine Necessity for Involuntary Commitment (DMH 572-01). A hearing is required to determine the appropriateness of the respondent’s: Continued inpatient treatment Outpatient treatment Discharge Conditional release and the respondent was committed as a result of conduct resulting in his being charged with a violent crime including a crime involving an assault with a deadly weapon, and the respondent was found not guilty by reason of insanity or incapable of proceeding to trial The respondent has failed to comply or clearly refuses to comply with all or part of the prescribed 0utpatient treatment. A report of reasonable efforts made to solicit the respondent’s compliance is attached. The respondent is an outpatient substance abuse commitment and intends to move or has moved to another county within the state. Attached is the Examination and Recommendation to Determine Necessity for Involuntary Commitment (DMH 572-01). The respondent is currently under inpatient commitment but now meets the criteria for outpatient commitment. Attached is the Examination and Recommendation to Determine Necessity for Involuntary Commitment (DMH 572-01). The respondent is a minor incompetent adult in a restrictive 24-hour facility as a hearing needs to be scheduled to determine whether the court concurs with the voluntary admission/continued stay. Treatment will be necessary beyond __________________ (Expiration date). Attached is the Evaluation for Admission/Continued Stay (DMH 573-01). If initial hearing, please attach copy of Application for Admission. The respondent was transferred to the above named facility on ____________(date) from __________________________________ (transferring facility) in ________________ County prior to the initial judicial commitment hearing initial judicial determination (involuntary minors and voluntary incompetent adults). The respondent, who is under substance abuse commitment, will require treatment in a 24-hour facility beyond 45 consecutive days. The 45 days will expire on _______________ (date). Attached is the Examination and Recommendation to Determine Necessity for Involuntary Commitment. Clerk: Please issue Subpoena To Testify to respondent for hearing requested above. DISTRIBUTION WHEN REQUEST TO RETURN IS ISSUED: Original: Clerk of Superior Court where facility is located _______________________________________________________ Outpatient or Substance Abuse – Clerk of Superior Court Signature & Title Where commitment is supervised CC: Medical Records NOTE: If current status is: Respondent’s Attorney, when applicable - Inpatient Commitment – must be signed by Attending Physician State’s Attorney, when applicable - Outpatient or Substance Abuse Commitment -- must be signed by * Respondant ** Petitioner Responsible Professional DMH 5-76-01 Revised September 2001 REQUEST FOR HEARING American LegalNet, Inc. www.USCourtForms.com