IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER CERTIFYING TRANSCRIPT OF FINAL COMMITMENT HEARING For West Virginia Resident Who is Nonresident of County [W.Va. Code: §27-5-4(n)(1)] This matter was heard on the __________ day of ___________________________, 20________, before the Honorable __________________________________________________________, Mental Hygiene Commissioner / Judge of the Circuit Court of __________________________ County, West Virginia. The Applicant in this cause, _____________________________, was represented by ____________________________________________, Assistant/Prosecuting Attorney of _______________ County, West Virginia; The Respondent appeared in person and by appointed counsel, __________________________________; Also present and testifying was _____________________________________________________ Physician/Psychologist. Testimony was also heard from [list witnesses]: __________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ____________________________________________________________________________________________ After hearing the testimony of witnesses and receiving all relevant evidence, and upon examination of the written report and certification of the Physician/Psychologist; Upon the arguments of counsel for the parties, the Commissioner / Court makes the following FINDINGS: The Respondent is a resident of ________________________________ County, West Virginia, and is neither a resident of, nor does Respondent reside in a mental health facility in, this County. The Commissioner / Court further FINDS that there is clear, cogent and convincing evidence which demonstrates [Initial Appropriate Items]: __________ The Respondent is addicted to the use of ________________________________________________________. __________ The Respondent is mentally ill. SCA-MH 917(n)(1)-1 / 6-06 of 2 § 27-5-4 ORDER CERTIFYING TRANSCRIPT OF FINAL COMMITMENT HEARING - Page 1 American LegalNet, Inc. www.FormsWorkflow.com The Commissioner / Court further FINDS that the facts supporting the finding of addiction and/or mental illness are as follows: ____________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________________ The Commissioner / Court further FINDS there is clear, cogent and convincing evidence which demonstrates that the Respondent is likely to cause serious harm to him/her self and/or others in the reasonably foreseeable future because of mental illness or addiction if allowed to remain at liberty, specifically: _____________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ____________________________________________________________________________________________ This Court further FINDS there is clear, cogent and convincing evidence which demonstrates that there is no less restrictive alternative to hospitalization of the Respondent, because: ____________________________________________________________ ___________________________________________________________________________________________________________ _________________________________________________________________________________________________ Additional findings of fact: _____________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ____________________________________________________________________________________________ Because of the facts hereinbefore recited, the Commissioner / the Court is satisfied that involuntary hospitalization should be ordered under the provisions of West Virginia Code: § 27-5-4(n)(2). Accordingly, it is hereby ORDERED that a transcript of the evidence of the Respondent's final commitment hearing in this County be certified by the Clerk of this Court to the Clerk of the Circuit Court of __________________________________ County, who shall immediately present such transcript to the Circuit Court or Mental Hygiene Commissioner of that County for further proceedings as required under West Virginia Code: § 27-5-4(n)(2). The Clerk shall enter the foregoing ORDER as of the day and date written below and shall transmit attested copies to Respondent's counsel of record, the Prosecuting Attorney of this County, and to the ______________________________________ Mental Health Center. ENTER this _______ day of _________________________________, 20 __________. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / JUDGE OF THE CIRCUIT COURT SCA-MH 917(n)(1)-1 / 6-06 of 2 § 27-5-4 ORDER CERTIFYING TRANSCRIPT OF FINAL COMMITMENT HEARING - Page 2 American LegalNet, Inc. www.FormsWorkflow.com