Petition - Commit Mentally Ill Child To Department Of Childrens Services
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Petition - Commit Mentally Ill Child To Department Of Childrens Services Form. This is a Tennessee form and can be use in Shelby Local County.
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Tags: Petition - Commit Mentally Ill Child To Department Of Childrens Services, JC-81A, Tennessee Local County, Shelby
IN THE JUVENILE COURT OF MEMPHIS AND SHELBY COUNTY, TENNESSEE
IN THE MATTER OF
Docket Number ____________________________
A child under 18 years of age
SUBPOENA AND NOTICE
STATE OF TENNESSEE
To any lawful officer:
Notify __________________________________________________________________________________
that a petition for his/her Judicial Hospitalization has been filed on the basis that he/she is mentally retarded and
thereby "poses a likelihood of serious harm" as defined in Tennessee Code Annotated § 33-5-305 and that
he/she is ordered to appear before the Juvenile Court of Memphis and Shelby County, Tennessee, at 616
Adams Avenue, Memphis, Tennessee, on the __________ day of ____________________, 20 ______,
at __________ o'clock ____ M., or as directed, to answer the Petition, a copy of which accompanies this Writ.
Further, that he/she has the right to be represented by counsel at the hearing.
Should the Court determine that he/she evidences a substantial risk of physical harm to himself/herself; or to
others; or an inability to protect himself/herself from harm, he/she will be committed to the custody and care of
the Commissioner of the Department of Mental Health and Mental Retardation.
Herein fail not, and have you then and there this Writ.
Witness, STEVE STAMSON, Clerk of said Juvenile Court, at office, in Memphis, Tennessee, this _______ day of
_________________________, 20 ______.
STEVE STAMSON, Clerk of Court
By __________________________________ D. C.
OFFICER'S RETURN
Came to hand ____________________, 20 _____, and executed by __________________________________
This ______ day of ________________, 20 ______
“for disability assistance, please call,”
TOM STONE (ADA COORDINATOR)
Phone (901) 379-7895
Email – Stone-t@co.shelby.tn.us
____________________________________________
Officer
7/15/05
JC–81A
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