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 )________________________________________________________ Application Incarcerated Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 Application Incarcerated Page 2 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 Application Incarcerated Page 3 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 Application Incarcerated Page 4 of 5 American LegalNet, Inc. www.FormsWorkFlow.com 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 Application Incarcerated Page 5 of 5 American LegalNet, Inc. www.FormsWorkFlow.com