IN THE CIRCUIT COURT OF _________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER / COMMISSIONER'S RECOMMENDATION FOR FINAL COMMITMENT: FOR RELEASE TO OUTPATIENT TREATMENT PURSUANT TO VOLUNTARY TREATMENT AGREEMENT [W.Va. Code: §§ 27-5-4 and 27-5-2(g)] This matter was heard on the __________ day of ___________________________, _________, before the Honorable [month] [year] _________________________________________________________, 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 _____________________________________________________________________, the examining Physician or Psychologist. Testimony was also heard from [list witnesses]: _____________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ After hearing the testimony of witnesses, receiving all relevant evidence, examination of the written report and certification of the Examiner, and hearing the arguments of counsel for the parties, the Commissioner / Court makes the following FINDINGS: [Initial Appropriate Items] ________ The Respondent is a resident of ___________________________ County, West Virginia. ________ The Respondent was found in ______________________________ County, West Virginia. ________ The Respondent is residing in a mental health facility in ____________________ County. ________ The Respondent is not a resident of the State of West Virginia, but is a resident of the State of ________________. 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 C CL MH08 INV 24; SCA-MH 907A / 8-08 _________________________________________________________. FINAL COMMITMENT VTA Page 1 of 4 American LegalNet, Inc. www.FormsWorkflow.com __________ The Respondent is mentally ill. 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 such 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 recommends / the Court concludes that involuntary hospitalization is required under the provisions of West Virginia Code: § 27-5-4. Notwithstanding the foregoing, the undersigned further FINDS that the Respondent's circumstances make him/her amenable to outpatient treatment in a nonresidential or non-hospital setting pursuant to a Voluntary Treatment Agreement: [state the evidence presented, or other basis, in support of this finding] ________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ C CL MH08 INV 24; SCA-MH 907A / 8-08 FINAL COMMITMENT VTA Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The undersigned further FINDS that appropriate outpatient treatment is available, to-wit:_____________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ The undersigned has also reviewed the Voluntary Treatment Agreement submitted by Respondent, dated the __________day of _______________________, ________, does hereby approve the same, a copy of which is attached hereto and made a part hereof, [month] [year] the contents of which are hereby incorporated herein by reference. The undersigned further RECOMMENDS / ORDERS that outpatient treatment pursuant to the Agreement shall remain in effect for [insert applicable time period] ________________________________________________________ which time period is: [initial applicable time period] ___________ Not more than six (6) months, inasmuch as the court hereby finds that the Respondent has not been involuntarily committed in the past two years. ___________ Not more than two (2) years, since the court hereby finds that the Respondent has been involuntarily committed in the past two years, to-wit: [insert date and place of last involuntary commitment] _________________________________________________________. Accordingly, it is hereby RECOMMENDED [by Commissioner] and ORDERED [by Judge]: 1. That the Respondent be conditionally released to outpatient treatment upon the terms and conditions set forth in the Voluntary Treatment Agreement. THIS RECOMMENDATION is made this _______ day of ____________________________, ________. [month] [year] _____________________________________________________________ MENTAL HYGIENE COMMISSIONER C CL MH08 INV 24; SCA-MH 907A / 8-08 FINAL COMMITMENT VTA Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com The foregoing findings and recommendations made on the ______ day of ___________________________, _________, by [month] [year] ___________________________________________________, Mental Hygiene Commissioner of this County, West Virginia, having been carefully and fully reviewed by this Court, are hereby adopted, approved and confirmed as the ORDER of the Circuit Court. The Clerk shall enter the foregoing ORDER as of the day and date written below and shall transmit three attested copies to the Sheriff of this County, one for presentation with the Respondent at the aforementioned mental health facility, and shall also 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 _________________________________, __________. [month] [year] ________________________________________________ JUDGE OF THE CIRCUIT COURT C CL MH08 INV 24; SCA-MH 907A / 8-08 FINAL COMMITMENT VTA Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com