PETITION FOR COMMITMENT FOR INVOLUNTARY TREATMENT AFTER FINDING OF INCOMPETENCY TO STAND TRIAL WHERE SEVERE MENTAL DISABILITY IS NOT PRESENT MENTAL HEALTH PROCEDURES ACT OF 1976 (SECTION 402B) NAME OF PATIENT NAME OF COUNTY PROGRAM NAME OF FACILITY LAST FIRST NAME OF BASE SERVICE UNIT ADMISSION DATE MIDDLE AGE SEX BASE SERVICE UNIT NUMBER ADMISSION NUMBER INSTRUCTIONS 1. This form is to be used for a petition for up to 30 days treatment under Section 402 B of the Mental Health Procedures Act of 1976 when a person has been found incompetent to stand trial but is not severely mentally disabled. 2. Part I is to be completed by the patient's attorney, the attorney of the Commonwealth, the County Administrator, the director of the patient's penal institution, etc. 3. Part II is to be used by the examining physician who has made a determination of incompetency to stand trial. 4. Part III is to be used at the court's discretion. 5. If additional sheets are needed at any point, note on this form the number of pages which are attached. IMPORTANT NOTICE ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON PURPOSE WHEN HE/SHE COMPLETES THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR. 1 American LegalNet, Inc. www.FormsWorkFlow.com MH 787 5/07 PART I PETITION FOR ORDER OF THE COURT ___________________________________________has been found to be incompetent to stand trial. He/she was examined (NAME OF PATIENT) by_____________________________________________, and it was found that he/she is in need of treatment, that it is (NAME OF DOCTOR) reasonably certain that such treatment will provide the patient with the capacity to stand trial, but that the patient is not severely mentally disabled. I request, therefore, that the court issue an order that the client by involuntarily committed for: inpatient, partial hospitalization, or outpatient treatment for a period of up to 30 days or until the client is competent to stand trial, (whichever comes sooner) under Section 402 B of the Mental Health Procedures Act of 1976. (SIGNATURE OF PETITIONER) (TITLE) (ADDRESS) (TELEPHONE NUMBER) (DATE) PART II RESULTS OF EXAMINATION (Statement of Physician) I hereby affirm that I have examined ________________________________________________________________ (NAME OF PATIENT) on __________________________ to determine if he/she is incompetent to stand trial and in need of treatment. (DATE) RESULTS OF EXAMINATION FINDINGS: (Give complete details of findings) TREATMENT NEEDED: 2 American LegalNet, Inc. www.FormsWorkFlow.com MH 787 5/07 PART II RESULTS OF EXAMINATION (Statement of Physician, continued) In my opinion: (Check A, B or C) A. B. C. The patient is incompetent to stand trial and 30 days of treatment can be reasonably certain to provide the patient with the capacity to stand trial. The patient is incompetent to stand trial but 30 days of treatment is not reasonably certain to provide the patient with the capacity to stand trial. The patient is not incompetent to stand trial. (SIGNATURE OF PETITIONER) (TITLE) PART III ORDER FOR INVOLUNTARY TREATMENT In the Court of _______________________________________ of _______________________________ County COMMONWEALTH VS. ___________________term, 20_____ __________________________________________________________No.__________________________________________ This _________day of ___________________, 20________ after hearing and consideration of: (Details of findings. Include details on what types and why treatment is needed. Attach reports, testimony, etc.) The court finds that the patient: (Check A, B or C) A. B. C. The patient is incompetent to stand trial and 30 days of treatment can be reasonably certain to provide the patient with the capacity to stand trial. The patient is incompetent to stand trial but 30 days of treatment is not reasonably certain to provide the patient with the capacity to stand trial. The patient is not incompetent to stand trial. 3 American LegalNet, Inc. www.FormsWorkFlow.com MH 787 5/07 PART III ORDER FOR INVOLUNTARY TREATMENT (continued) FURTHER, AFTER HEARING AND CONSIDERATION OF: (Details of findings. Include details on what types and why treatment is needed. Attach reports, testimony, etc.) The court orders that: (Check A or B) A. _______________________________________receive outpatient, partial hospitalization, inpatient (NAME OF PATIENT) treatment, which is the least restrictive treatment setting appropriate for the patient. (Description of treatment, explanation of its adequacy and appropriateness. as a person incompetent to stand trial but not severely mentally disabled pursuant to the provisions of Section 402 B of the Mental Health Procedures Act of 1976 for a period of _________________days (not to exceed 30 days). B. Other: (Check appropriate block) The patient was represented by_________________________________________________________________ (NAME AND ADDRESS OF ATTORNEY) The patient declined representation. for the court____________________________________________ ______________________________________________________ (TITLE) 4 American LegalNet, Inc. www.FormsWorkFlow.com MH 787 5/07