IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER / COMMISSIONER'S RECOMMENDATION: GRANTING FINAL COMMITMENT OF A NONRESIDENT OF WEST VIRGINIA [W.Va. Code: §27-5-4(p)] This matter was heard on the __________ day of ___________________________, ________, before the Honorable [month] [year] __________________________________________________________, Mental Hygiene Commissioner / Judge of the Circuit Court of this County. The Applicant in this cause, ________________________________________________, was represented by _________________________________________, Assistant/Prosecuting Attorney of this County; 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, 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 ________________________________________________________. __________ The Respondent is mentally ill. C CL MH08 INV 35; SCA-MH 917(p) / 8-08 FINAL COMMITMENT OF NON-RESIDENT Page 1 of 4 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 Commissioner / 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: ________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ And further, the Court finds that the current address of the Respondent is ________________________________________ _______________________________________________________________________________________________________, and the date of birth of the Respondent is ___________________________________________________________. Additional findings of fact: ____________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________________________________ C CL MH08 INV 35; SCA-MH 917(p) / 8-08 FINAL COMMITMENT OF NON-RESIDENT Page 2 of 4 American LegalNet, Inc. www.FormsWorkflow.com 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. Accordingly, it is hereby RECOMMENDED [by Commissioner] and ORDERED [by Judge]: 1. That the Respondent be committed, for the time period specified below, to the custody of the Secretary of the Department of Health and Human Resources and be admitted to _____________________________________________________________ mental health facility, or such other facility as determined appropriate by said Department. 2. That the Respondent be remanded to the custody of the Sheriff of this County, who shall immediately transport the Respondent to such facility. 3. That the commitment herein ordered shall be [initial one] __________ for a temporary period of observation not to exceed six (6) months, or __________ for an indeterminate period not to exceed two (2) years, unless, previous to the expiration of this period, this order is modified or extended by further order of this Court pursuant to the provisions of West Virginia Code: § 27-5-4(k)(3) and (4). And further, pursuant to West Virginia Code § 61-7-7(a)(4), Respondent is hereby notified that all individuals who have been involuntarily committed to a mental institution in West Virginia are required to immediately surrender any firearms in their ownership or possession. Upon consideration of the testimony available at the final commitment hearing in this matter, it is further recommended/determined that the appropriate public or private individual or entity to act as a temporary conservator of such firearm property to be immediately surrendered by Respondent is ____________________________________________________, until such time as this firearm matter may be more fully heard by the Circuit Court of this County. THIS RECOMMENDATION is made this _______ day of ________________________________, ________. [month] [year] _________________________________________________________ MENTAL HYGIENE COMMISSIONER C CL MH08 INV 35; SCA-MH 917(p) / 8-08 FINAL COMMITMENT OF NON-RESIDENT Page 3 of 4 American LegalNet, Inc. www.FormsWorkflow.com The foregoing findings and recommendations made on the _______ day of ______________________________, _______, [month] [year] by ______________________________________________, 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 is hereby directed to immediately transmit an attested copy of this Order to the Secretary of the Department of Health and Human Resources pursuant to the provisions of West Virginia Code: § 27-5-4(p). The Secretary of the Department of Health and Human Resources, or his or her designee, shall make appropriate arrangements for transfer of the Respondent to the State of the Respondent's residence, stated herein, which shall be conditioned upon the agreement of the Respondent except as qualified by the interstate compact on mental health. 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 35; SCA-MH 917(p) / 8-08 FINAL COMMITMENT OF NON-RESIDENT Page 4 of 4 American LegalNet, Inc. www.FormsWorkflow.com