NOTICE OF INTENT TO FILE A PETITION FOR EXTENDED INVOLUNTARY TREATMENT AND EXPLANATION OF RIGHTS (303) This notice is to inform you that: 1. intends to file an application with the Court of Common Pleas to extend your involuntary treamtent for up to 20 more days. (NAME OF PETITIONING FACILITY) 2. The court will consider this petition within 24 hours after it is filed. You will be informed of the time and place of the conference as soon as it is set. 3. You will be given a copy of the petition when it is filed. It will detail the specific conduct and medical diagnosis of your examining doctor which will be considered by the court. 4. You have the right to be represented by a lawyer at the conference. If you cannot afford to hire a lawyer, the court will appoint a lawyer for you. 5. You will be permitted to attend the conference. You and your lawyer will have the right to question your examining doctor and any other witnesses and to present information on your behalf. 6. If your conference is before a Mental Health Review Officer and if you are not satisfied with the results of your conference, you have the right to ask for a hearing before a judge of the court. The court will hold a conference, review all the evidence presented, and make its own decision as to whether you should be discharged or receive further treatment. 7. In addition to the above rights, you continue to have the rights described in the patient's bill of rights. If you have lost or misplaced your copy, ask for another copy. If you have any questions regarding your rights under these procedures you may ask: (NAME OF MENTAL HEALTH WORKER) (SIGNATURE OF EXAMINING DOCTOR OR MEMBER OF TREATMENT TEAM) American LegalNet, Inc. www.FormsWorkFlow.com MH 784A 7/07 AVISO DE INTENCI�N DE PRESENTAR UNA PETICI�N UNA EXTENSI�N DEL TRATAMIENTO INVOLUNTARIO Y EXPLICACI�N DE DERECHOS (303) Esta noticia es para informarle: 1. registrar� una aplicaci�n en la Corte de Litigios Ordinarios con el prop�sito de extender su tratamiento involuntario hasta 20 d�as m�s. (NOMBRE DE LA INSTITUCI�N PETICIONARIA) 2. La Corte considerar� est� petici�n dentro de 24 horas, despu�s de haber sido registrada. Se le informar� el tiempo y lugar de la conferencia tan pronto se determinado. 3. Se le dar� una copia de la petici�n cuando sea registrada. Se detallar� su conducta espec�fica y el diagn�stico m�dico del doctor examinador para consideraci�n de la corte. 4. Tiene el derecho de que un abogado lo(la) represente durante la audiencia. Si no est� en condiciones de pagar los honorarios de un abogado, el tribunal asignar� uno para que lo(la) represente. 5. Se le permitir� asistir a la conferencia. Ud. y su abogado tienen derecho a cuestionar al m�dico examinador y cualquier otro testigo. Adem�s, puede presentar informaci�n en su propia defensa. 6. Si comparece ante el Oficial Revisor de Salud Mental y no est� satisfecho con los resultados de la conferencia, tiene derecho a requerir una vista ante un juez de la corte. En conferencia de corte, toda la evidencia presentada es repasada y el juez decidir� si debe ser dado de alta o seguir recibiendo tratamiento. 7. En adici�n a los susodichos derechos, ud. retiene los derechos descritos en la Carta del Derechos del paciente. Si eso se le ha perdido y no sabe donde la puso, pida otra copia. Si tiene alguna pregunta en relaci�n a sus derechos bajo estos procedimientos, puede preguntarle a: (NOMBRE DEL TRABAJADOR DE SALUD MENTAL) (FIRMA DEL DOCTOR EXAMINADOR O MIEMBRO DEL TEAM DE TRATAMIENTO) American LegalNet, Inc. www.FormsWorkFlow.com MH 784A-S 7/07