Page 1 of 5 MH - 784 4 /2019 APPLICATION FOR EXTENDED INVOLUNTARY TREATMENT MENTAL HEALTH PROCEDURES ACT OF 1976 (SECTION 303) (The blanks below may be completed following admission) NAME OF PATIENT LAST FIRST MIDDLE AGE SEX NAME OF COUNTY PROGRAM NAME OF BSU BSU NO. NAME OF FACILITY ADMISSION DATE ADMISSION NO. INSTRUCTIONS 1. Part I must be completed by the petitioner. The petitioner will generally be the director, acting director, or appropriate designated staff within the facility where the patient is being treated. 2. Part II is to be completed by persons authorized by the director of the facility to explain rights to the patients. 3. Part III is to be completed by a physician who has personally examined the patient. 4. Part IV is to be completed by a judge or a Mental Health Review Officer. 5. If additional sheets are needed at any point, note on this form the number of pages which are attached. 6. Attach a copy of the treatment plan and the 302 form , prior to delivery to the court. 7. The patient sh all receive a copy of form MH 784 - A, a copy of this petition, and a copy o f the 302 form when this 303 form is filed with the court. 8. If the patient is subject to criminal proceedings/detention, briefly describe below. IMPORTANT NOTICE ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON PURPOSE WHEN COMPLETING THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR. American LegalNet, Inc. www.FormsWorkFlow.com Page 2 of 5 MH - 784 4 /2019 PART I REQUEST FOR CERTIFICATION has acted in such manner as to cause a responsible party (NAME OF PATIENT) to believe that he/she is severely mentally disabled, and needs extended involuntary treatment . He/she was admitted to for involuntary emergency examination and (NAME OF FACILITY) treatment on (D ATE ) (DATE) at (EXACT TIME) (EXACT TIME under Section 302. He/she was examined by and was found to be in need of continued involuntary treatment tre tretreatment treatment. (NAME OF PHYSICIAN) Inpatient treatment under Section 301(b)(1) or (2) Outpatient treatment under Section 301(b)(1) or (2) Partial hospitalization under Section 301(b)(1) or (2) A ssisted O utpatient T reatment (AOT) under Section 301(c) AOT is defined as community - based outpatient social, medical and behavioral health treatm ent services ordered by the court for a severely mentally ill person which may include community psychiatric supportive treatment, assertive community treatment, medication, individual or group therapy, peer support services, financial services, housing or sup ervised living services, co - occurring alcohol or substance abuse treatment, and any other services . I respectfully request, therefore, that he/she be certified by the court for extended involuntary emergency treatment under Section 303. (SIGNATURE OF PETITIONER) (DATE) (TITLE OF PETITIONER) PART II THE RIGHTS I affirm that I have informed the patient of the actions I am taking and have explained to the patient these procedures and his/her rights as described in f orm MH 784 - A and , for AOT form MH - 789 - B . I believe that he/she understands, does not understand these rights. (SIGNATURE OF PERSON GIVING RIGHTS) (DATE) American LegalNet, Inc. www.FormsWorkFlow.com Page 3 of 5 MH - 784 4 /2019 PART III EXAMINATION I hereby affirm that I have examined on (NAME OF PATIENT) to determine if he/she continued to be severely mentally ill and in need of treatment. (DATE) RESULTS OF EXAMINATION FINDINGS: (Describe your findings in detail. Use additional sheets if necessary.) * Note: Information regarding Substance Use Disorder (SUD) treatment is subject to specific confidentiality requirements under state and federal law, including 71 P.S. 247 1690.108 and 42 CFR 247 2.64. If the person subject to the AOT petition does not consent to disclosing confidential SUD treatment information to the court or counsel, a separate petition for authorization should be filed with the court and an order obtained prior to disclosure. TREATMENT NEEDED: (Describe the treatment needed by the patient. If AOT is recommended, you MUST provide an AOT plan using form MH - 790 . Continue on additional sheets if necessary ). American LegalNet, Inc. www.FormsWorkFlow.com Page 4 of 5 MH - 784 4 /2019 In my opinion: (Check A , B or C ) : A. T he patient continues to be severely mentally disabled and in need of involuntary inpatient , outpatient or partial hospitalization treatment or a combination under Section 301(b)(1) or (2) . B. The patient continues to be severely mentally disabled and in need of AOT under Section 301( c) . C. The patient is not severely mentally disabled and in need of involuntary treatment. (SIGNATURE OF EXAMINING OR TREATING PHYSICIAN) (DATE) PART IV CERTIFICATION BY THE COURT FOR EXTENDED INVOLUNTARY EMERGENCY TREATMENT - SECTION 303 In the court of of County term, 20 In re: No. CERTIFICATION FOR EXTENDED TREATMENT This day of , 20 after hearing and consideration of (Details of findings. Include details as to what type and why treatment is needed. Attach repo rts, testimony, AOT plan (MH - 790 form) , etc.) American LegalNet, Inc. www.FormsWorkFlow.com Page 5 of 5 MH - 784 4 /2019 The court finds that the patient is , is not , severely mentally disabled and in need of treatment. Accordingly, the court orders that: (Check A or B below) A. (NAME OF PATIENT) receive: I npatient treatment under Section 301(b)(1) or (2) O utpatient treatment under Section 301(b)(1) or (2) P artial hospitalization under Section 301(b)(1) or (2) AOT under Section 301(c) which is the least restrictive treatment setting appropriate for the patient of as a severely mentally disabled person pursuant (NAME OF FACILITY) to the provisions of section 303 of the Mental Health Procedures Act of 1976 for a period of . (NOT TO EXCEED 20 DAYS) (Check appropriate block) T he person is , is not subject to medication management under an AOT order. If the person is subject to medication management as part of an AOT order, the prescribing physician at the designated AOT facility is authorized to perform routine medication management including adjusting medications and doses , in consultation with the person subject to this order, and as warranted by B. The person is not subject to involuntary treatment. I have explained to the patient that if his/her conference was before a Mental Health Review Officer he/she may petition the court for a review of any decisions reached at this conference. (Check appropriate block) The patient was represented by (NAME OF ATTORNEY) (ADDRESS OF ATTORNEY) The patient declined representation. for the court (TITLE) American LegalNet, Inc. www.FormsWorkFlow.com