IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT MOTION FOR INVOLUNTARY HOSPITALIZATION DUE TO NONCOMPLIANCE WITH VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §27-5-2(h)] The undersigned, _____________________________________________________, who is (relationship to Respondent) __________________________________________________ hereby moves this Court for an order involuntarily hospitalizing the Respondent pursuant to the provisions of West Virginia Code: §27-5-3. In making this motion, the undersigned represents: 1. The Respondent has failed or refused to comply with the terms and conditions of the Voluntary Treatment Agreement in the following manner: [detail circumstances where Respondent has either failed or refused to comply with the agreement, referencing parts of the agreement and the dates of noncompliance, if applicable] ____________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________[attach additional pages as necessary]. 2. The undersigned further believes that the Respondent remains: [check applicable condition(s)] __________ Addicted and as a result of addiction is likely to cause serious harm to him/her self and/or others. __________ Mentally ill and as a result of mental illness is likely to cause serious harm to him/her self and/or others. Wherefore, your movant would request that this Court enter an order setting this motion for hearing and further commanding the Sheriff to take into custody, detain, and bring the Respondent before this Court for disposition of the motion. Respectfully presented this ______ day of ______________________________, 20 ________. ________________________________________________________________ MOVANT SCA-MH 907C / 6-06 VTA NON-COMPLIANCE MOTION Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com