IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER / COMMISSIONER'S RECOMMENDATION: GRANTING COMMITMENT TO RESPONSIBLE PERSON [W.Va. Code: §27-5-4(o)] This matter was heard on the __________ day of ___________________________, 20________, before the Honorable __________________________________________________________, 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, and upon the arguments of counsel for the parties, the Commissioner / Court makes the following FINDINGS [Initial Appropriate Items]: The Respondent _________IS _________IS NOT a resident of ___________________________ County, West Virginia. The Respondent _________WAS _________WAS NOT found in ______________________________ County, West Virginia. The Respondent __________IS residing in a mental health facility in ____________________ County. __________IS NOT __________ 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. SCA-MH 917(o)-1 / 6-06 § 27-5-4(o) ORDER FOR FINAL COMMITMENT TO RESPONSIBLE PERSON- Page 1 of 3 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 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. The Commissioner / Court also FINDS that a responsible person has agreed to take care of the Respondent, to-wit: ____________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ SCA-MH 917(o)-1 / 6-06 § 27-5-4(o) ORDER FOR FINAL COMMITMENT TO RESPONSIBLE PERSON- Page 2 of 3 American LegalNet, Inc. www.FormsWorkflow.com ___________________________________________________________________________________________________________ _________________________________________________ in lieu of this Court's ordering the Respondent to a mental health facility. Accordingly, it is hereby RECOMMENDED [by Commissioner] and ORDERED [by Judge]: 1. That the Respondent be committed to the care and custody of ___________________________________________________, a Responsible Person, under the provisions of West Virginia Code: § 27-5-4(o), until further order of this Court. 2. That the Responsible Person named above post bond with this Court in the amount of $ ___________________________, with approved surety, conditioned upon said Responsible Person's restraining and taking proper care of the Respondent until the further order of this Court. If the amount of bond space is not completed above, no bond is being recommended / required. THIS RECOMMENDATION is made this _______ day of ______________________________, 20 ________. ______________________________________________________M ENTAL HYGIENE COMMISSIONER The foregoing findings and recommendations made on the _______ day of _____________________________, 20 _______, 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 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 _________________________________, 20 __________. ______________________________________________________ JUDGE OF THE CIRCUIT COURT SCA-MH 917(o)-1 / 6-06 § 27-5-4(o) ORDER FOR FINAL COMMITMENT TO RESPONSIBLE PERSON- Page 3 of 3 American LegalNet, Inc. www.FormsWorkflow.com