Authorization And Order To Return Escaped Patient To Mental Health Facility
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Authorization And Order To Return Escaped Patient To Mental Health Facility Form. This is a West Virginia form and can be use in Circuit Court Statewide.
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Tags: Authorization And Order To Return Escaped Patient To Mental Health Facility, SCA-MH-920CMO, West Virginia Statewide, Circuit Court
NOTICE TO RETURN ESCAPEE TO MENTAL HEALTH FACILITY
IN RE: Involuntary Hospitalization of
Case No. ________- MH -________
___________________________________
RESPONDENT
AUTHORIZATION AND ORDER:
TO RETURN ESCAPED PATIENT TO MENTAL HEALTH FACILITY
[W.Va. Code: §27-7-5]
TO THE SHERIFF OF ______________________ COUNTY, WEST VIRGINIA:
Pursuant to the provisions of West Virginia Code: § 27-7-5, YOU ARE HEREBY COMMANDED to take into custody
and to transport back to the
______________________________________________________________________________________ mental health facility the
following patient who has escaped therefrom:
Name of Patient:
___________________________________________________________________________________
Patient's Description:
___________________________________________________________________________________
___________________________________________________________________________________________________________
Patient's Last Known Address:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
A person who is taken into custody under this notice and the provisions of West Virginia Code: § 27-7-5, may be detained,
but not incarcerated in a jail or penal institution, for a period not in excess of fourteen (14) hours, pending return to the mental health
facility named above. Pursuant to West Virginia Code: § 27-7-5, THE SHERIFF MAY EXECUTE THIS ORDER IN ANY
PART OF THE STATE OF WEST VIRGINIA.
Given under my hand this _________ day of ______________________________________, 20 _______.
____________________________________________________________
CHIEF MEDICAL OFFICER OF FACILITY
SCA-MH 920CMO / 6-06
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