IN THE CIRCUIT COURT OF ________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: DISMISSAL OF FINAL COMMITMENT PROCEEDINGS [W.Va. Code: §27-5-4] 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. Additional evidence was presented by ________________________________________________________________________. 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 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 Court further FINDS that there is clear, cogent and convincing evidence which demonstrates [Initial Appropriate Items]: __________ The Respondent is addicted. __________ The Respondent is mentally ill. The Court further FINDS there is clear, cogent and convincing evidence which demonstrates that the Respondent [initial one] __________IS __________ IS NOT 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. SCA-MH 915-1 / 6-06 § 27-5-4 DISMISSAL ORDER Page 1 of 2 American LegalNet, Inc. www.FormsWorkflow.com The specific facts upon which these findings are based are as follows: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ______________________________________________________________ This Court further FINDS there is clear, cogent and convincing evidence which demonstrates that: __________ THERE IS __________ THERE IS NOT a less restrictive alternative to hospitalization of the Respondent, namely: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ _______________________________________________________________________________________ Accordingly, it is hereby ORDERED that the proceedings in this matter initiated by the Applicant are DISMISSED and the Respondent is hereby RELEASED from custody. The following particular matters are noted in the granting of this dismissal: ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ __________________________________________________________________________________ The Clerk shall enter the foregoing ORDER as of the day and date first above written and shall transmit attested copies to the Applicant, the Chief Medical Officer of the mental health facility, to Respondent's counsel of record, the Prosecuting Attorney of ____________________________ County, and to the ___________________________________________________________ Mental Health Center. ____________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE SCA-MH 915-1 / 6-06 § 27-5-4 DISMISSAL ORDER Page 2 of 2 American LegalNet, Inc. www.FormsWorkflow.com