IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: ___________________________________________________ [Name of Licensed Independent Clinical Social Worker, Advanced Nurse Practitioner with Psychiatric Certification, or Physician Assistant] Case No. ___________-P____________ ORDER: DENYING AUTHORIZATION TO PERFORM EXAMINATIONS FOR PROBABLE CAUSE PROCEEDINGS FOR INVOLUNTARY HOSPITALIZATION [W.Va. Code: §27-5-2(e)] On the _______ day of ____________________, _______, came Petitioner and presented to the Court his/her report/request [month] [year] and qualifications for court authorization pursuant to West Virginia Code § 27-5-2 to perform probable cause examinations for proceedings for involuntary hospitalization. This Court has reviewed said report/request and qualifications, and upon consideration of all, it is, ORDERED, that the Petitioner does not/no longer meets the requirements of West Virginia Code § 27-5-2, and/or is not/no longer authorized to perform the examinations for probable cause proceedings for involuntary hospitalization pursuant to Article 5, Chapter 27 of the West Virginia Code. The Clerk of this Court is directed to record this Order in the appropriate Order Book of this Court and to transmit copies to Petitioner, the Mental Hygiene Commissioner(s) of this County, any Magistrate designated by the Chief Judge of this Judicial Circuit to accept involuntary hospitalization applications and hold probable cause hearings, and the Administrative Office of the West Virginia Supreme Court of Appeals. _____________________________________________________________ CIRCUIT COURT JUDGE C CL MH08 EXAM 3; SCA-MH 924D / 8-08 Authorization Denial Order Page 1 of 1 American LegalNet, Inc. www.FormsWorkflow.com