PETITION FOR INVOLUNTARY TREATMENT VIA THE CRIMINAL JUSTICE SYSTEM MENTAL HEALTH PROCEDURES ACT OF 1976 (SECTIONS 304 AND 305 VIA 403, 404 OR 405) (The blanks below may be completed following admission.) 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. Part I, the petition for order of the court, is to be completed by the director of the facility (or his authorized representative) where the patient is currently incarcerated, the attorney for the Commonwealth, the defendant's counsel, or the County Administrator. 2. Part II is to be completed by persons authorized by the director of the facility to explain rights to patients, if the patient is currently in treatment. If the patient is not currently in treatment, it should be completed by the penal institution or the patients attorney. 3. Part III is to be completed by the examining or treating physician. If the patient is not currently in treatment and has not been examined by a physician, this section may be completed on order of the court under Section 304 (c) (5) of Act 143. 4. Part IV is to be completed by the court if use of this format is desired. 5. If additional sheets are needed at any point, note on this form the number of pages which are attached. 6. If the patient is currently in involuntary treatment, attach a copy of the treatment plan and a copy of the 304 form, prior to the delivery of this form to the court. IMPORTANT NOTICE ANY PERSON WHO PROVIDES ANY FALSE INFORMATION ON PURPOSE WHEN HE COMPLETES THIS FORM MAY BE SUBJECT TO CRIMINAL PROSECUTION AND MAY FACE CRIMINAL PENALTIES INCLUDING CONVICTION OF A MISDEMEANOR. PAGE 1 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com MH 786 5/07 PART I PETITION FOR ORDER OF THE COURT _____________________________has acted in such a manner as to cause me to believe that he is severely mentally disabled. (NAME OF PATIENT) He/she has been examined by _______________________________and was found in need of treatment. (NAME OF DOCTOR) He/she has not been examined by a physician, but I believe he is in need of treatment. I, therefore, request that: (Check and complete A, B or C) A. As the patient is not currently in a mental health facility receiving treatment, I ask this court to issue an order that the patient be involuntarily committed for: outpatient, partial hospitalization, inpatient treatment. (A patient can only be committed involuntarily if the patient is severely mentally disabled.) A person is severely mentally disabled: A person is severely mentally disabled when, as a result of mental illness, his capacity to exercise self-control, judgement and discretion in the conduct of his affairs and social relations or to care for his own personal needs is so lessened that he poses a clear and present danger of harm to others or to himself. Clear and present danger to others shall be shown by establishing that within the past 30 days the person has inflected or attempted to inflict serious bodily harm on another and that there is reasonable probability that such conduct will be repeated. A clear and present danger of harm to others may be demonstrated by proof that the person has made threats of harm and has committed acts in furtherance of the threat to commit harm; or Clear and present danger to himself shall be shown by establishing that within the past 30 days: (i) the person has acted in such manner as to evidence that he/she would be unable, without care, supervision and the continued assistance of others, to satisfy his need for nourishment, personal or medical care, shelter, or self-protection and safety, and that there is reasonable probability that death, serious bodily injury or serious physical debilitation would ensue within 30 days unless adequate treatment were afforded under the act; or the person has attempted suicide and that there is the reasonable probability of suicide unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger may be demonstrated by the proof that the person has made threats to commit suicide and has committed to acts which are in further of the threat to commit suicide; or the person has substantially mutilated himself or attempted to mutilate himself substantially and that there is the reasonable probability of mutilation unless adequate treatment is afforded under this act. For the purposes of this subsection, a clear and present danger shall be established by proof that the person has made threats to commit mutilation and has committed acts which are in furtherance of the threat to commit mutilation. (ii) (iii) (Describe the behavior of the patient within the last 30 days which causes you to believe that he is severely mentally disabled. Use additional sheets if necessary.) PAGE 2 OF 6 American LegalNet, Inc. www.FormsWorkFlow.com MH 786 5/07 PART I PETITION FOR ORDER OF THE COURT (continued) B. As the patient is currently in (Name of Facility)_______________________________________receiving involuntary treatment under Section 303, I ask that the court issue an order that the patient be involuntarily committed for outpatient, partial hospitalization, inpatient treatment. As a patient currently in (Name of Facility)_______________________________________receiving involuntary treatment under Section 304, I ask that this court issue an order that the patient be involuntarily committed for another period of outpatient, partial hospitalization, inpatient treatment. C. (SIGNATURE OF PETITIONER) (TITLE) (ADDRESS) (TELEPHONE NUMBER) (DATE) PART II THE PATIENT'S RIGHTS I affirm that I have informed the patient of the actions I am taking and have explained to him these procedures and his rights as described in Form MH 786-A. I believe that he: understands these rights does not understand these rights (SIGNATURE OF PETITIONER) (TITLE) American LegalNet, Inc. www.FormsWorkFlow.com PAGE 3 OF 6 MH 786 5/07 PART III RESULTS OF EXAMINATION AND DETERMINATION OF NEED FOR (CONTINUED) TREATMENT I hereby affirm that I have [ examined (DATE) reexamined ] ____________________________________________ continues to be ] severely mentally disabled and in (NAME OF PATIENT) on __________________________ to determine if he/she [ is need of treatment. RESULTS OF EXAMINATION (Give complete details of examination. If request is for a 304 (b) or 305, describe details giving evi