IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT CHIEF MEDICAL OFFICER'S APPLICATION FOR FINAL COMMITMENT [W.Va. Code: §§ 27-5-3(g), 27-4-3(c), and 27-5-4(c)] INSTRUCTIONS: Please type or print clearly all requested information and check any and all spaces which may be applicable. The application may be denied if essential information is omitted or unreadable. A Form INV 10 / Form 904 evaluation certificate must be submitted with this application and must be attached. I, ________________________________________, M.D., Chief Medical Officer of ________________________ ____________________________, mental health facility, hereby make application to the Circuit Court of the above named county for an order of final commitment of the above named Respondent and request that final commitment proceedings be held pursuant to the provisions of West Virginia Code: § 27-5-4, et seq., and that the basis for this application is as follows: 1. [Initial the appropriate provision and complete] ________ The Respondent was admitted to this facility on [insert date of admission to facility] _________________ for further evaluation and treatment in accordance with West Virginia Code: § 27-5-2 and 3 pursuant to an Order of the Circuit Court of ____________________________ County, West Virginia, being the county where said Respondent [check the following based upon the findings contained in the probable cause order] _____ resides and/or _____ was found. ________ This application is being made in accordance with West Virginia Code: § 27-4-3(c) within 96 hours of a request for release by Respondent, a voluntary patient at the above identified mental health facility who was admitted to this facility on [insert date of admission to facility]____________________________. NOTICE: If involuntarily committed, the voluntary patient 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 C CL MH08 INV 26; SCA-MH 907K / 8-08 APPLICATION FINAL COMMITMENT Page 1 of 3 American LegalNet, Inc. www.FormsWorkflow.com (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. ___________ [Initial] THE NAMED RESPONDENT HAS BEEN OFFERED VOLUNTARY TREATMENT, BUT HAS EITHER REFUSED 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. 2. Based upon physician's examination as the same appears in the attached certificate [attach Form 904 certificate], the undersigned believes that the Respondent is: [check applicable diagnosis] ______________ Addicted, and because of such addiction is likely to cause serious harm to himself/herself or others, and/or ______________ Mentally ill, and because of such mental illness is likely to cause serious harm to himself/herself or others. 3. The grounds for such belief are as follows: [state, in detail, the factual basis for such belief and a detailed listing of any and all recent overt acts upon which the belief is based]: _______________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The treatment recommended for the Respondent is not available in a setting less restrictive than a hospital with 24 hour-perday supervision for the following reasons: ________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ C CL MH08 INV 26; SCA-MH 907K / 8-08 APPLICATION FINAL COMMITMENT Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________________________________________ I, the applicant whose signature appears below, under penalties of false swearing as provided by law, do hereby certify that the facts and allegations contained in this application are true to the best of my knowledge, information and belief, and insofar as they are stated to be upon information, I believe them to be true. Given under my hand this ______ day of _____________________, _______. (month) (year) ______________________________________________ CHIEF MEDICAL OFFICER The foregoing application was taken, subscribed and sworn to (or affirmed) before me, the undersigned notary public, this _________ day of ____________________, ________. (month) (year) [affix notarial seal here] ____________________________________________________ NOTARY PUBLIC C CL MH08 INV 26; SCA-MH 907K / 8-08 APPLICATION FINAL COMMITMENT Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com