IN THE CIRCUIT COURT OF _________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT AUTHORIZATION AND ORDER: CUSTODY AND TRANSPORT [RETURN] TO MENTAL HEALTH FACILITY [W.Va. Code: §27-7-4] On the _______ day of ____________________, 20_____, came _______________________________________, Chief Medical Officer for ______________________________________________________________ mental health facility and presented to the Court a sworn notice that _____________________________________________________ was admitted to such mental health facility by involuntary commitment Order of this Court and was released under the provisions of West Virginia Code: § 27-7-2 or 3. Said sworn notice further states that there is reason to believe that it is in the best interests of the Respondent to be hospitalized and stated certain facts concerning the condition of the patient, the contents of which notice are hereby incorporated herein by reference. This Court FINDS the Notice sets forth facts which are sufficient to meet the requirements of West Virginia Code: § 27-7-4, and is further satisfied that the condition of the Respondent warrants his/her return to the mental health facility. Accordingly, it is ORDERED that any health officer or police officer and/or the Sheriff of this County is hereby authorized to take the Respondent into custody and to transport him/her to ________________________________________________________ __________________________________ mental health facility. _____________________________________________________________ JUDGE OF THE CIRCUIT COURT SCA-MH 920 / 4-02 American LegalNet, Inc. www.FormsWorkflow.com