IN THE CIRCUIT COURT OF __________________ COUNTY, WEST VIRGINIA IN RE: Involuntary Hospitalization of Case No. ________- MH -________ ___________________________________ RESPONDENT ORDER: DISMISSAL OF INVOLUNTARY HOSPITALIZATION PROCEEDINGS BASED UPON REPORT OF PHYSICIAN OR PSYCHOLOGIST [W.Va. Code: §27-5-4(f)(3)] An application to institute final commitment proceedings was filed in this matter on the __________ day of ___________________________, 20________, by ____________________________________________________, M.D., Chief Medical Officer of _______________________________________________________________ mental health facility. On the______ day of_______________________________, 20_______, this Court reviewed the report of __________________________________________________________, the physician/psychologist previously appointed to examine the Respondent, the contents of which report are hereby incorporated herein by reference. The undersigned judicial officer hereby FINDS that the report does not confirm the Respondent is addicted and/or mentally ill, or if such report does confirm that the Respondent is mentally ill or addicted, then it does not confirm that the Respondent, because of such condition, might be harmful to self and/or others. Accordingly, it is hereby ORDERED that these proceedings for involuntary hospitalization are DISMISSED pursuant to the provisions of West Virginia Code: §27-5-4(f)(3). 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 this County, and to the ____________________________________________________________________ Mental Health Center. ___________________________________________________________________________ MENTAL HYGIENE COMMISSIONER / CIRCUIT JUDGE SCA-MH 914 / 6-06 American LegalNet, Inc. www.FormsWorkflow.com