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Application For Involuntary Custody For Mental Health Examination For Individual Incarcerated Form. This is a West Virginia form and can be use in Circuit Court Statewide.
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Tags: Application For Involuntary Custody For Mental Health Examination For Individual Incarcerated, SCA-MH-901C, West Virginia Statewide, Circuit Court
IN THE CIRCUIT COURT OF ______________ COUNTY, WEST VIRGINIA
For Clerk's Use Only
IN RE: INVOLUNTARY HOSPITALIZATION OF ___________________________________, RESPONDENT
DATE: ____________________________________________ CASE NUMBER ___________ - MH - __________
If this application is GRANTED, distribute copies of the application and Form INV 4 or 5 ORDER to: Applicant,
Respondent, Respondent's Attorney, Prosecuting Attorney and the Regional Mental Health Center.
APPLICATION FOR INVOLUNTARY CUSTODY FOR
MENTAL HEALTH EXAMINATION
OF INDIVIDUAL INCARCERATED IN A JAIL, PRISON,
OR OTHER CORRECTIONAL FACILITY
[West Virginia Code: § 27-5-2(a)(2) ]
INSTRUCTIONS TO CHIEF ADMINISTRATIVE OFFICER OF CORRECTIONAL FACILITY:
A.
B.
C.
D.
1.
All information must be printed or typed and be clearly readable.
All information requested must be provided, if known. If unknown, you must state it is unknown.
Any petition and application that does not provide the necessary information, or is unreadable, may be rejected or denied.
Read and answer all questions carefully.
In this document, the RESPONDENT is the incarcerated individual whose examination is being requested.
FULL NAME OF INCARCERATED PERSON TO BE EXAMINED [RESPONDENT]:
______________________________________________________________________________________________________________
Identification Information
of Respondent::
DATE OF BIRTH ____/_____/________; WEIGHT __________;
HAIR COLOR ________________; HAIR LENGTH ___________;
SEX ________; HEIGHT __________; EYE COLOR ______________; RACE ______________.
2.
RESPONDENT'S LAST KNOWN ADDRESS PRIOR TO INCARCERATION: _____________________________________________
______________________________________________________________________________________________________________
3.
PLACE OF BIRTH [state or country]________________________________________________________________________________
4.
THE RESPONDENT IS:
A.
B.
5.
A RESIDENT OF ___________________________________ COUNTY, ______________________ STATE.
CURRENTLY PRESENT IN ___________________________________ COUNTY, __________________ STATE.
NAME OF CORRECTIONAL FACILITY AT WHICH RESPONDENT IS NOW BEING HELD: _____________________
______________________________________________________________________________________________________________
6.
ADDRESS OF CORRECTIONAL FACILITY: _______________________________________________________________________
______________________________________________________________________________________________________________
CORRECTIONAL FACILITY TELEPHONE NUMBER: (
C CL MH08 INV 2; SCA-MH 901C / 11-09
)________________________________________________________
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7.
CHIEF ADMINISTRATIVE OFFICER'S FULL NAME : _____________________________________________________________
WORK PHONE NUMBER OF CHIEF ADMINISTRATIVE OFFICER: (
)_________________________________
PLEASE PROVIDE A WAY TO CONTACT YOU PENDING THIS APPLICATION PROCESS (example: cell phone, pager number). THE
COURT MUST BE ABLE TO REACH YOU AND NOTIFY YOU OF THE TIME AND PLACE OF ANY HEARING. FAILURE OF FACT
WITNESSES WITH FIRSTHAND KNOWLEDGE OF RESPONDENT'S CONDITION AND BEHAVIOR TO APPEAR AT THE HEARING
MAY RESULT IN THE APPLICATION BEING DISMISSED AND THE RESPONDENT BEING RETURNED TO YOUR
CORRECTIONAL FACILITY. If you do not want the Respondent to have this information, you may supply the information separately to the Court.
PHONE NUMBER TO REACH CHIEF ADMINISTRATIVE OFFICER: _________________________________________
8.
DO YOU BELIEVE THE RESPONDENT IS:
A.
ADDICTED TO DRUGS, ALCOHOL AND/OR OTHER SUBSTANCES?
__________YES
__________NO
B.
MENTALLY ILL?
__________YES
__________NO
9.
HOW LONG HAS THE RESPONDENT SHOWN SUCH BEHAVIOR ? ______________________________________________
10.
IN YOUR OWN WORDS, PROVIDE ANY INFORMATION WHICH SUPPORTS YOUR BELIEF THAT THE RESPONDENT IS
ADDICTED AND/OR MENTALLY ILL:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
______________________________________________________________________________________________________
________________________________________________________________________________________________________________
(Attach additional pages if necessary)
11.
DO YOU BELIEVE THE RESPONDENT, BECAUSE OF MENTAL ILLNESS OR ADDICTION, IS LIKELY TO CAUSE SERIOUS
HARM TO :
A.
__________YES
__________NO
B.
12.
HIM/HER SELF?
OTHER PEOPLE?
__________YES
__________NO
LIST ANY AND ALL RECENT ACTS WHICH SUPPORT YOUR BELIEF THAT THE RESPONDENT IS LIKELY TO CAUSE
SERIOUS HARM TO HIM/HER SELF AND/OR OTHERS. INCLUDE APPROXIMATE DATE(S) WHEN EACH ACT OCCURRED:
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________________
(Attach additional pages if necessary)
A.
IS RESPONDENT A SUICIDE RISK?
_______ YES
_______ NO
________ UNKNOWN
IF YES, EXPLAIN: _______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
C CL MH08 INV 2; SCA-MH 901C / 11-09
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B.
IS RESPONDENT VIOLENT?
_______ YES
_______ NO
_______ UNKNOWN
IF YES, EXPLAIN: _______________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
13.
LIST THE NAMES AND ADDRESSES OF OTHER PERSONS WHO HAVE SEEN THE BEHAVIOR OR CONDITION OF THE
RESPONDENT:
__________________________________________________________________________________________________________________
______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
___________________________________________________________________________________________________________
IF YOU WANT THESE PEOPLE TO APPEAR AT HEARING ON THIS APPLICATION, YOU MUST CONTACT THEM
DIRECTLY.
14.
IS THE RESPONDENT CURRENTLY HOSPITALIZED?
_________ YES
___________ NO
IF YES, STATE WHERE HOSPITALIZED AND EXPECTED LENGTH OF STAY IN HOSPITAL: ____________________________
______________________________________________________________________________________________________________
15.
HAS THE RESPONDENT BEEN UNDER THE RECENT CARE OF A PHYSICIAN ? ________YES ________NO
IF YES, STATE PHYSICIAN'S NAME, ADDRESS, AND PHONE NUMBER: ____________________________________________
______________________________________________________________________________________________________________
16.
IS THE RESPONDENT IN NEED OF MEDICAL CARE FOR ANY PHYSICAL CONDITION OR DISEASE? _____ YES _____ NO
IF YES, DESCRIBE THE CONDITION/DISEASE: ___________________________________________________________________
______________________________________________________________________________________________________________
17.
IS THE RESPONDENT TAKING ANY MEDICATIONS?
_________ YES
_________ NO
IF YES, LIST THE MEDICATIONS AND DOSAGE: _________________________________________________________________
________________________________________________________________________________________________________________
____________________________________________________________________________________________________________
18.
DOES THE RESPONDENT NEED MEDICAL CARE, TREATMENT, OR HOSPITALIZATION THAT WOULD PREVENT
EXAMINATION BY A MENTAL HEALTH PROFESSIONAL OR A COURT APPEARANCE?
A.
_________YES
_________NO
B.
19.
IMMEDIATELY?
WITHIN THE NEXT 24 HOURS?
_________YES
_________NO
HAS THE RESPONDENT BEEN EXAMINED BY A PSYCHIATRIST OR PSYCHOLOGIST ? _______YES ________NO
IF YES, STATE PSYCHIATRIST'S OR PSYCHOLOGIST'S NAME, ADDRESS, AND DATE OF LAST EXAMINATION:
________________________________________________________________________________________________
________________________________________________________________________________________________
20.
HAS THE RESPONDENT EVER BEEN DIAGNOSED WITH MENTAL RETARDATION?
C CL MH08 INV 2; SCA-MH 901C / 11-09
_______YES ________NO
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21.
HAS THE RESPONDENT EVER BEEN CONFINED IN A HOSPITAL FOR MENTAL ILLNESS OR ADDICTION ?
_____ YES
______ NO
IF YES, STATE THE REASON FOR HOSPITALIZATION, THE FACILITY IN WHICH THE RESPONDENT WAS HOSPITALIZED,
AND THE DATE(S) OF HOSPITALIZATION:
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
22.
NOTICE INFORMATION - YOU MUST COMPLETE THIS SECTION:
A. Respondent's Spouse:
________________________________
Name
________________________________
City, State, Zip
____________________________
Address
____________________________
Telephone
B. Respondent's Parents/Guardians:________________________________
Name(s)
________________________________
City, State, Zip
_________________________
Address
____________________________
Telephone
C. Respondent's Next-of-Kin:
____________________________
Address
____________________________
Telephone
________________________________
Name
________________________________
City, State, Zip
23.
________________[initial] THE HEREIN NAMED CORRECTIONAL FACILITY AT WHICH THE
RESPONDENT IS INCARCERATED CANNOT REASONABLY PROVIDE TREATMENT AND OTHER
SERVICES FOR THE RESPONDENT'S MENTAL ILLNESS OR ADDICTION.
24.
_______________ [initial] THE NAMED RESPONDENT HAS BEEN OFFERED VOLUNTARY TREATMENT,
BUT HAS EITHER REFUSED APPROPRIATE VOLUNTARY HOSPITALIZATION AND/OR TREATMENT, OR
IS IN A MENTAL OR MEDICAL CONDITION PRECLUDING HIS OR HER ABILITY TO CONSENT TO
VOLUNTARY HOSPITALIZATION AND/OR TREATMENT.
NOTICE:
If involuntarily committed, the person against whom you are filing this application, will be:
(1) prohibited from possessing and receiving firearms and ammunition, in some cases for his or her entire life,
(2) required to immediately surrender ANY firearms owned or in his or her possession,
(3) if committed for treatment of mental illness, reported to both federal and state database registries used for
firearm purchases and permits/licenses to carry concealed weapons, and
(4) subject to future criminal charges for possession or receipt of firearms or ammunition. Conviction in West
Virginia can result in a fine up to $1,000.00 or jail time of up to one year. Federal conviction is a FELONY and
can result in fines and jail time up to TEN years. (See, W.Va. Code § 61-7-7 and 18 U.S.C.A. § 924(a)(2))
Persons seeking voluntary admission for treatment, who have NOT been involuntarily committed, are NOT
subject to these prohibitions and requirements.
C CL MH08 INV 2; SCA-MH 901C / 11-09
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I, ____________________________________________________, the Applicant and Chief Administrative Officer of the
[print YOUR name here]
__________________________________________________________ correctional facility, hereby certify that I truly believe that
[print NAME OF CORRECTIONAL FACILITY here]
the Respondent, ________________________________________________________ is
[print RESPONDENT'S name here]
[check applicable category(s)] _____addicted and/or _____ mentally ill and because of mental illness or addiction is likely to cause
serious harm to him/her self and/or others if allowed to remain at liberty, and should, therefore, be taken into custody for examination
and treatment. I therefore petition that the Respondent be brought before Court in order that the Court may determine what further
actions, if any, are warranted according to the provisions of the West Virginia Code: § 27-5-2.
I understand that MALICIOUS MAKING OF AN APPLICATION to any circuit court or mental hygiene commissioner
for the purpose of having another person declared mentally ill or an inebriate is a crime and can result in fine or imprisonment up to
one year, or both. West Virginia Code: § 27-12-1.
I further certify, UNDER PENALTIES OF FALSE SWEARING as provided by law, that the information, statements and
allegations contained in this Petition and Application are true and accurate to the best of my knowledge, information and belief and
constitute the sole basis and reasons for the making of this application. I understand that if I knowingly provide FALSE information
in the application, I could be subject to a criminal charge of false swearing.
[NOTE: APPLICATION MUST BE MADE UNDER OATH/NOTARIZED OR WILL BE DENIED]
DATE: __________________________
_____________________________________________________________
CHIEF ADMINISTRATIVE OFFICER'S SIGNATURE
The foregoing Petition and Application was subscribed and sworn to or affirmed before the undersigned authority this
_______ day of ___________________, 2 _____.
[if notary - affix Notarial Seal]
_____________________________________________________________
NOTARY PUBLIC/ CIRCUIT CLERK
My Commission Expires: _________________________________.
C CL MH08 INV 2; SCA-MH 901C / 11-09
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